Tommy John surgery saved Shohei Ohtani and saved hundreds of pitchers’ careers… but 50 years after it was first performed, the man who rebuilt MLB’s $700 million star fears

A thick scar runs along Shohei Ohtani’s right arm. Further evidence also lingers under the skin.

‘I would hope you would say, “This looks like a normal ligament…”‘ says Dr. Neal ElAttrache, the surgeon trusted to put Ohtani and many of the sport’s biggest stars back together. “Just a little bit thicker.”

That’s the legacy of two surgeries over five years aimed at rebuilding the elbow of baseball’s most prized asset. The hope for both doctor and patient? That scar will fade and in time the only giveaway will only be visible via MRI.

Back in December, a few months after the second round of surgery, the Los Angeles Dodgers gave Ohtani a $700 million contract — the richest contract in sports history. It was a nine-figure vote of confidence in ElAttrache and a procedure that over the past five decades has saved billions of dollars and thousands of careers.

Ohtani isn’t slated to play again until 2025 after tearing his ulnar collateral ligament for a second time. The Dodgers are gambling on the two-way star rediscovering the level that made him a two-time MVP. A risky bet? Well, Ohtani has already done it once. And so have plenty of others.

According to Kerlan-Jobe Institute, more than 90 percent of pitchers return to their prime after undergoing Tommy John surgery, the groundbreaking procedure first pioneered by Frank Jobe 50 years ago. Simply put, surgeons reconstruct the UCL by transplanting a replacement tendon—usually from the forearm or hamstring. And according to ElAttrache, it is ‘the most impactful, most important and most successful reconstructive procedure in sports.’

In fact, the operation has developed such a mythology that many coaches and parents have considered putting players under the knife – even before their elbow is injured.

‘Tommy John is the king. I don’t think there is any procedure we do that is as important in sports as that, says ElAttrache. And yet disaster looms, with baseball battling a crisis on the mound.

“The numbers are pretty overwhelming,” says ElAttrache, the Dodgers’ head physician. More than 30 percent of MLB pitchers have had Tommy John surgery at some point in their careers, including 38 within the past 13 months. The Guardian’s Shane Bieber and Atlanta star Spencer Strider are among the latest – it’s been a brutal start to the 2024 season. According to ESPN’s MLB Injury Status, about 80 pitchers are currently nursing elbow problems.

Astros’ Justin Verlander labeled the current spate of injuries a ‘pandemic.’ ElAttrache calls it an ‘explosion’. And the number of players who, like Ohtani, tear the ligament again and need another operation is also growing.

“Their effort and performance is greater than it used to be,” says the surgeon. ‘So if you can tear the ligament that God put in your elbow. You can tear it as I reconstruct it.’

MLB is involved in a public row with its players union after reducing the time between pitches. Experts like ElAttrache cannot offer a simple solution. Just a warning.

“There is no doubt that we are exceeding the maximum capacity of this ligament – at a higher and higher rate,” says ElAttrache.

Surgeons have already had to modify Tommy John to help pitchers withstand today’s demands. And ElAttrache fears that the day may come when existing medical procedures simply ‘can’t keep up’.

‘I never underestimate the demands of the human body. And I try not to overestimate what I as a person can do to fix it,’ he says. “Unfortunately, what can end up happening is that it will continue… until enough of them tear apart that we just can’t do an operation good enough to get them back.”

ElAttrache honed his craft under Jobe, the man who switched sports medicine in September 1974.

“One of the most talented, beautiful surgeons I’ve ever seen in my life,” he says. However, what made Jobe ‘head and shoulders above his peers’ was his ‘eternal quest for learning and research and experimentation’.

This thirst for innovation led him to a groundbreaking procedure. That’s how long a torn UCL would end a pitcher’s career; Jobe believed his operation might have a 1 percent chance of success. But former Dodgers pitcher Tommy John returned to the mound for another 14 years.

‘One of the reasons this came about was because of the emergence of multi-year, big-money contracts,’ explains ElAttrache. “The teams invested more in their players.” And in baseball, many of those dollars were guaranteed.

‘So if you got injured in the first year of your contract and the team had already invested in you, they were more willing to do whatever it took to get you fixed.’ Before then, teams simply moved on to another.

“Remarkably, the concept of the operation hasn’t changed very much in 50 years,” says ElAttrache. But advances on the mound have given surgeons new problems to solve.

“The biggest thing is that the style of pitching has changed so much — everybody is throwing the ball as hard as they possibly can and spinning the ball as hard as they possibly can,” Verlander said recently.

Back in 1974, ElAttrache explains, the average MLB pitcher hit about 88 miles per hour. Now it’s about 94; now every team has a guy who can reach 100 km/h. And even small changes in speed require ‘enormous’, ‘exponentially greater’ strain.

“So we’ve had to figure out ways to improve the procedure,” says ElAttrache. In addition to transplanting a new tendon, some surgeons now add an ‘internal brace’ for extra support.

Time will tell if Ohtani’s ‘enhanced reconstruction’ is as successful as his first in 2018. ‘Before his Tommy John surgery, he was (pitching) at 98 mph. In March 2023, he was clocked at 103.5 mph,” ElAttrache says.

‘Everyone was ecstatic.’ It spoke of the success of his work. And still? “I was maybe the only person on the planet who was a little concerned.” The doctor sensed that increased speed was a ‘harbinger’ of the wound – and he was right. ElAttrache also knows that improvements after surgery can present another problem. For a while, surgeons were forced to battle coaches and parents who wondered: why wait until a pitcher is injured to get a Tommy John?

“They saw that so-and-so famous pitcher injured himself, had the surgery, and he was able to throw as well or better after the surgery,” he explains. ‘It’s still a common thought… if you get Tommy John surgery, you’re better than God made you.’

The reality? “That’s simply not the case,” says ElAttrache. Because in the season(s) leading up to a UCL tear, pitchers’ stats often begin to decline. ‘So they are back where they were before they began their death.’

Surgeons are busy enough at the moment without having to dispel myths or offer simple solutions.

“This explosion of injuries is not just because of one thing,” says ElAttrache. ‘It’s not just because of the time between pitches. It’s not just because they can no longer use sticky things on their fingers’.

It’s not just because pitchers are now trained from childhood to throw as fast – or with as much spin as possible. ‘It’s hard to show that any one of these things is the culprit because it’s not that, it’s the combination.’

Verlander agrees. “Put everything together and everything has a bit of an impact,” he said. “I don’t know how you rewind the clock.”

All being well, Ohtani will throw his first simulated game in late September — nearly 50 years to the day since the first ever Tommy John surgery.