September 5, 2005
St. Paul, Minn. — In the mid-1970s, Los Angeles Dodger pitcher Tommy John was in the prime of his career. But that was about to change.
"I was at the game and he threw one pitch that went into the stands," says Dr. Frank Jobe, the team's doctor at the time.
Right away he suspected that John, a left-hander, had damaged the main ligament on the inside of his left elbow. He also knew the fate of most of the pitchers who suffered from that injury.
"They went back to their hometown and got a job. Because that was what they used to think of as blowing your arm out. And then they couldn't pitch," says Jobe.
He diagnosed a torn Unlar Collateral Ligament in the elbow. At the time, there was no way to repair the damage surgically.
"I kind of thought he was through," says Jobe.
But he also said that John did not want to give up on his baseball career.
"I might not have done it if he hadn't been the kind of person he was, in that he was very smart," says Jobe. "And he said, 'I don't want to quit.' He said 'I've got to get this fixed.' And finally we came up with the idea of what to do, and he came back and said 'let's do it.'"
What Dr. Jobe did was take a tendon from John's right forearm, one the body has little use for, and put it in his left elbow.
"I had done that before in a polio patient to stabalize an ankle," says Jobe. "And so I knew that was a good source of tendon. And hand then surgeons were using that particular tendon to replace tendons in the fingers when they had been severely damaged."
In the surgery, Dr. Jobe drilled a hole through the bone of the upper arm above John's left elbow, and drilled another hole in the Ulnar bone below the elbow. Then he threaded the tendon through the first hole in the upper arm, pulled it down past the funny bone, and through the hole in the lower arm. The tendon was long enough to do this multiple times, up and down, in a figure eight pattern. Then, he tucked the ends of the tendons inside the bones, where they could get a good supply of blood. He wanted the tendon to attach itself to the bones, like the ligament.
"I thought I could do the operation and fix it. The thing I didn't know is whether the body would accept it and make it part of the elbow, in other words, would it last. He began to feel good pretty quick. But I didn't want him to start throwing, because we weren't sure if the tendon had assimilated yet," says Jobe.
Instead, he wanted John to rehab. But there was no established program for the new procedure. So, Jobe made one up on the fly. The program he developed was an early version of what Twins reliever Grant Balfour is going through this summer. He had Tommy John surgery in May, after he had trouble with his throwing arm.
"I was throwing and I felt I strained my forearm. I didn't really feel anything in my elbow. It was my forearm compensating for my elbow," says Balfour.
Balfour is a long way from his native Australia. He is working out in a rehab room in Edina. Tommy John specialists, including Dr. Jobe, say physicians have almost perfected the operation. It is the grueling 12 month rehab that has become the biggest factor in a pitcher's attempt to come back from the injury. And it is the rehab that has seen the most improvement since Tommy John's recovery in the '70s. Doctors have developed an elaborate rehab protocol that includes a set of milestones to be reached over the 12 months. And the rehab on the arm begins right after the operation.
"It's in a brace. And it's locked up, right here, across your body," says Balfour. "You can't move it. And it stays like that for a week. And each week, on this brace, they have a dial, which opens up the amount of degrees you can use your arm. So it goes from being immobile to the amount of mobility you do have is very limited, such as maybe 30 degrees, then 60 degrees, then 90 degrees. And you eventually get it to where you can straighten it. And then once the brace comes off, you have to work on stretches and the rehab."
Balfour still needs to build strength, and he does that with Carolyn Flood, his physical therapist. She is going to help him do special strength exercises called manuals.
"So, now what we're doing over the course of this time is some more shoulder strengthening for Grant," says Flood.
Balfour begins this session by lying down on his back on the edge of a padded table. His arm is extended outward, and she is standing next to him. He begins to wave his arm back and fourth. She is constantly pushing back against his arm. "I'm just giving him resistance instead of him doing it with a weight, I'm adding it," says Flood. "And he does it quite fast, so I have to keep up."
She says manuals are good because she can resist his arm muscles in both directions, never allowing him to rest. Balfour says doing manuals day after day has become tedious. But it is now more than three months since his operation, and he is on the verge of a new milestone.
"I can start to actually start to throw 15 feet, with like a little weighted ball into a wall. I can actually start to throw for the first time," says Balfour.
Two weeks after that, if all goes well, Balfour can expect to throw a real baseball 30 feet, nice and easy. Then he can throw 60, 90 and 120 feet. Each is a milestone over another two or three months. Then, he should be able to throw batting practice.
Former Twins starting pitcher Joe Mays was throwing batting practice just as Balfour was having his elbow diagnosed this spring. Mays was finishing his Tommy John recovery, after missing all of last season. In an interview at the Metrodome, Mays talked about Tommy John surgery being a psychological battle as well as a physical one. He even struggled with the decision to have the operation.
"You know, going into it I was real scared," says Mays. "You have thousands of questions. What's the the percentage of coming back to where you were? What's the rehab like? How long is it? How long do I have to wait before I can throw a ball? You've just got millions and millions of questions."
The success rate for Tommy John surgery for major leaguers is about 93 percent, according to Dr. Jobe. After his surgery, Mays was dedicated to his rehab program, maybe too dedicated. He tried to accelerate his rehab when his elbow began to feel fine. He tried throw his trademark sinker ball earlier than scheduled.
"That's where I don't think the ligament was quite ready for that and I think that's where I had the setback," says Mays.
A subsequent operation to remove scar tissue made him physically healthy again as this season began. But Mays' comeback this year has been up and down. He pitched well in the first half of the season, but after the All Star break in July, he has struggled. He was recently demoted to the bullpen. The Twins and Mays have not said whether his arm is worn out because of the surgery.
The long road back for Tommy John ended in 1976 when he took the mound with his own worries about whether his arm would hold up for a whole season. The answer was yes -- and then some. He went on to pitch 14 more years in the big leagues, two years longer than he had pitched before his now famous operation.