A rise in elbow injuries has depleted the on-field product for MLB

Virtually every baseball fan knows the story of Tommy John. The left-handed pitcher was a good pitcher for the first 10 years of his career, then his ulnar collateral ligament exploded on him in the middle of the 1974 season. Dr. Frank Jobe, perhaps the best orthopedic surgeon of the time, formulated a procedure that would hopefully heal John's shattered elbow.

Dr. Jobe removed a tendon from Tommy John's wrist in his right arm, drilled 4 holes in John's left elbow, and weaved the wrist tendon in and out to replace the useless ligament. This procedure had never been done before, and while it has been modified a few times throughout history, Tommy John Surgery (not named after Dr. Jobe because, in his own words, "[John] himself did the hard work. He developed a rehabilitation program that stood the test of time") has become the de facto route for baseball players the world over to recover from a torn UCL. After the surgery, John would pitch for 16 more years, attend 3 more All-Star Games, and place second in Cy Young Voting twice.

Since 1974, there have been a total of 2,424 reported total procedures from a splattering of surgeons. Several more have likely been performed without documentation, and plenty of other players opted for another procedure over having Tommy John Surgery. Dr. Frank Jobe, Dr. Lewis Yocum, Dr. Neal ElAttrache, and Dr. James Andrews are perhaps the most seasoned of surgeons for this procedure. Individuals ranging from age 13 (Hayden Hurst in 2007) all the way to age 47 (Jamie Moyer in 2012) have had Tommy John Surgery.

Since the end of the 2023 MLB regular season, there have been 14 players who have gone under for Tommy John Surgery. Big-name starting pitchers such as Shane Bieber, Eury Perez, Sandy Alcantara, Felix Bautista, and Jackson Kowar have had the surgery. Gerrit Cole, perhaps the best pitcher in Major League Baseball, is also out with an elbow injury, though he deferred the procedure on Dr. Neal ElAttrache's advice. Not even position players are safe, as Pittsburgh Pirates' young catcher Endy Rodriguez even underwent surgery to repair his ruptured UCL. Atlanta Braves ace Spencer Strider looks to be the next victim of an elbow epidemic.

Reporters, doctors, and physiologists have tried for decades to explain the causes of a rise in elbow procedures. In his book titled The Arm: The Billion-Dollar Mystery of the Most Valuable Commodity in Sports, ESPN reporter Jeff Passan presents quite a few reasons. Passan traversed the globe for three years to figure out the root causes of elbow injuries. He met with players from high school to international leagues to the majors. He spoke with coaches from Japan to Kansas and everywhere in between. He met with a plethora of specialists all to find an answer as to why players' arms are ailing more now than ever before.

Passan asserted three root causes of arm injuries: overuse at a young age, an unnatural pitching motion, and a rapid increase in velocity.

Young baseball players are exposed (forced?) into national tournaments at young ages. While these tournaments do have certain restrictions on their pitchers, a good portion of the decision-making still rests on the shoulders of the coaches and parents. One of the most premier baseball tournaments each year is hosted by Perfect Game. While Perfect Game's origins are a bit questionable, players who attend their camps and showcases get noticed. You can find their rest rules here; you'll notice pitch count restrictions and days of rest are not the most conservative of limits.

The overhand throwing motion is not something that is developmentally natural to the human body. The amount of force that is generated on an elbow when a pitcher twirls his arm ranges from 50-120 Newtons, a range that exceeds joint failure in the UCL. In fact, the arm is not even the primary generator of velocity when throwing; the lower body and shoulder are mostly responsible for velocity. Regardless, the true origins of elbow injuries can be traced back to 1884 when overhand pitching was allowed for the first time.

The final, and probably most damning cause of a rise in elbow injuries, can be attributed to velocity. The chart below details the average velocity of fastballs and sliders paired with the amount of elbow procedures in Major League Baseball since 2008. The compilation of surgeries comes courtesy of Jon Roegele who maintains an accurate list of surgeries. This list also includes players who received Platelet-Rich Plasma (PRP) injections, which started being tracked in 2008, and those who received internal braces, a process that was instituted in 2016; however, non-MLB players are removed from the tabulation.

Since 2008, slider velocity has increased by 1.8 MPH, and fastball velocity has surged by 2.3 MPH. Elbow surgeries have increased at a near-commensurate rate; in 2008, only 15 players actively in the majors underwent Tommy John Surgery or received a PRP injection. 2021 featured the greatest amount of elbow procedures with a grand total of 40. Perhaps the most correlative aspect of an increase in Tommy John procedures is velocity. This year alone, 10 MLB players have received some form of treatment on their elbows, and we are only in the month of April. This pace would surpass the high set in 2021.

*Caveat: the pitch clock has not been shown to be a substantial factor in the rise in elbow injuries. Position players getting hurt debunks that theory. Additionally, the pitch clock was not present in 2021, the year with the most injuries.

While the St. Louis Cardinals have yet to be struck by the UCL epidemic this year (jinx), they have had several players recently undergo the procedure. Players like Dakota Hudson (2020), Jordan Hicks (2019), Trevor Rosenthal (2017), Alex Reyes (2017), Marco Gonzales (2016), Lance Lynn (2015), and even Adam Wainwright (2011) have received Tommy John Surgery.

The rise in elbow injuries could also explain the front office's hesitancy to sign free agents or trade for starters. An organization knows its own players best; the Cardinals' lack of signings and trades for pitchers recently could be explained by a fear of the unknown with elbows.

We may never truly be able to figure out all of the causes behind a rapid rise in ulnar collateral ligament injuries. The best we as fans, and human beings in general, can hope for is an improvement in awareness, research, and surgery.