Tommy John Surgery and the Training of Young Athletes
Injury rates in youth sports continue to climb -- is there a way to correct that trend?
Scrolling through social media, I saw a shocking statistic: kids between the ages of 15-19 account for 57% of all Tommy John surgeries. Named after the Los Angeles Dodgers pitcher who was the guinea pig for the procedure, this surgery replaces a torn ligament in the elbow with another ligament sourced from either elsewhere in the patient’s body or from a cadaver.
The ulnar collateral ligement (UCL) connects the humerus to the ulna, i.e. the bone of the upper arm to one of the two bones of the forearm. It functions much like the ACL (anterior collateral ligament) in the knee: it connects bones across a joint and help move the joint through its intended range of motion. Ligaments often act as a line of last defense for a joint by stabilizing it when the surrounding muscles give out. This is what happens in non-contact ACL injuries: a player makes a cut or lands in such a way that the muscles around the knee do not absorb the force imposed on the joint so the force goes to the ligaments, and sometimes that results in the ACL tearing.
A baseball player undergoes a Tommy John surgery because he has torn his UCL, either partially or completely. For Tommy John himself, the new experimental procedure was a last resort. Until that point in 1974, a UCL tear was a career-ending injury for a pitcher. Without the stability provided by a healthy ligament, you cannot throw at peak velocity. The surgeon gave John 100-1 odds of a successful outcome. But John, already a 10-year MLB veteran, went on to pitch for 14 more seasons which included three All-Star game appearances. Subsequently, the procedure extended hundreds of professional pitching careers that would have otherwise abruptly ended.
The initial group of Tommy John surgery patients were seasoned players — most had already spent time in the major leagues and the rest were minor league players. That is to say, all of them were well into a professional career before getting the surgery. But currently, teenagers are the largest cohort undergoing this surgery — looking back at the top of this article, 57% of all Tommy John surgeries are performed on kids between 15-19 years old. Why is this the case?
Baseball as a sport has not fundamentally changed, but youth sports culture has significantly changed over the past few decades. Driven by enormous player salaries and greater exposure of professional leagues in daily life, youth sports have become an ultra-competitive multi-billion dollar industry. The number of spots at the professional level has remained roughly the same over the past few decades, but the amount of kids vying for those spots has more than doubled since 1971. That creates greater pressure to excel at earlier ages, to peak sooner rather than later. Seasons only exist nominally — practice and training last the entire year. By the time a kid enters high school, it is likely that they are already focused exclusively on a single sport.
That all comes at enormous costs, both physically and psychologically. Performing thousands of repetitions of a very specific, high-velocity movement always makes for joint wear and tear; if done prior to physical maturity, the likelihood of injury is much higher. Injuries in full-contact sports come with the territory at every level; non-contact injuries, especially ones that require surgery, should be exceptionally rare in youth sports. But the number of serious joint injuries continues to climb not just in baseball but in all sports — for example, ACL injuries in all high school athletes increased 25.9% between 2007-2022. With higher rates of participation and more early specialization, the injury rates will likely climb higher in the future. Even if a young athlete avoids injury, they often experience burnout by age 13.
It doesn’t have to be this way, and the solutions are pretty simple. The challenge is that the alternative approach goes against what is currently trendy and aims for long-term success into adulthood rather than winning at the youth level. While truly gifted athletes should be developed into superhuman pros, sports ought to be a platform for success at other endeavors and instill the habit of regular physical exertion. The scope of the training program needs to look multiple years ahead rather than a single year, a few months, or just a few weeks. A proper training program also needs to account for psychological stress to prevent both burnout and physical injury. Below are a few principles to build a healthy young athlete:
Start with General Movements
Many kids get thrown into a sport before an introduction to general physical activity, the inverse of a proper progression. From single-digit ages into the pre-teen years, kids should build a general base of skills involving jumping, running, and calisthenics. Mechanics should always be refined, and good technique will come from a combination of practice and physical maturity. To make these basic exercises more engaging, they can be practiced in the context of a game rather than through a specific sport.
Starting with general movements has two primary benefits. The first is that the young athlete build a broad pool of skills that provide a strong physical foundation to build upon. What sense does it make to start playing basketball if a kid can’t run or jump properly? Mastering general movements before specialization goes a long way into greater levels of development into a sport and prevents injuries.
The second benefit is psycological. Most kids will have difficulty with specific motions in sports such as throwing a baseball. The more specific and the faster the motion, the harder it is to gain proficiency let alone mastery. A lack of technical proficiency leads many kids to quit sports in frustration at a very young age, long before they physically mature to an appropriate age to develop those sports-specific skills. As a result, far too many kids are written-off as non-athletes and fall away from regular physical activity for the rest of their lives.
Start Strength Training Early
Strength training doesn’t mean immediately putting a barbell in their hands. Those general movements mentioned above should include push ups, pull ups, and bodyweight squats — simple and general exercises. Once they are proficient in those exercises, it’s easy to transition to loaded versions.
In the beginning stages of strength training, the weights should remain light with proper technique as the focus of the workouts. Avoid max attempts until they have consistently good technique and are more physically mature. A kid won’t have the hormones to make scheduled progress until their early-mid teens, so it’s pointless to focus on weight until that stage. But it’s better to start early and get proper technique drilled — it’ll go a long way into making them a better athlete and staving off injuries.
Always Stick to the Basics
Once entered into a sport, those general movements and exercises need to remain a staple of the training program. Constantly build the base even as the athlete further specializes. An analogy used by many successful strength & conditioning coaches is that of a pyramid: the broader the base, the higher the peak can go. Currently, most athletes’ physical development looks more like a spire: small base with a sharp peak. Without that broad base, it’s more difficult for an athlete to reach their full potential and the liklihood of injury increases. Even at the highest levels, but especially with young athletes, you can never have too strong of a physical foundation.
Help the Athlete Keep Persective
When you’re young, it’s difficult to think long-term. Patience comes with age. One of the biggest challenges in working with kids is to keep them focused on future success rather than immediate wins. Coaching exercises and writing programs is much easier than getting athletes to stick to the program and wait for results. Training is often tedious and can get boring at times. Individual workouts are components of a long process rather than a bunch of performances. Kids often can’t think beyond a few days let along a few years. Helping athletes get the proper perspective on the process will allow everything else to fall into place.
To wrap up, we can reverse the trend of youth sports injuries. The current trends exist because of the failures of coaches to properly train their athletes. Coaches and parents need to help their kids focus on life-long success where sports are simply part of well-rounded development. Keep things simple, always practice the basics, do some strength training, and think long-term.