Young baseball pitchers increasingly seeking elbow surgery once reserved for professionals

Editor's Note: The author (Jennifer Streeter @jennystreeter3) is receiving her Master's degree from the Columbia University Graduate School of Journalism on May 17. She wrote this Tommy John surgery and youth pitchers story for her thesis.

A Division I pitcher, 19-year old Sang Ho Baek, is fitted in his green and yellow No. 44 George Mason University baseball jersey. On his left hand is his favorite glove he’s religiously cared for throughout his career. His teammates surround him, loved ones look on.

He is their central focus.

But instead of being on the pitching mound, Baek is in a casket.

“It is heartbreaking for me to think about my son,” said Baek’s father, Seong Han Baek. “He was my son, but he was also my friend.”

In 2021, after a routine elbow procedure, Baek became the first known pitcher to die after what’s known as Tommy John surgery. The cause of death: pulmonary embolism.

While Dr. Wiemi Douoguih, former Washington Nationals team doctor, and other surgeons say the procedure is considered safe, there are risks. He knows them well. Douoguih performed the surgery on Baek and attended his open-casket visitation 18 days later.Leading elbow and shoulder sports orthopedic surgeon Dr. James Andrews, among two other top surgeons in the field, said the frequency of ulnar collateral ligament reconstruction surgery performed on young people has reached epidemic levels. The age range of patients is rapidly decreasing and some are resulting in medical malpractice cases, even death.

“The number one group is youth baseball having more surgeries, more than the professionals,” said Andrews, who is based in Gulf Breeze in the Florida Panhandle. “Because of this trend we’re seeing, we're trying to figure out how to prevent these youth injuries and keep these kids out of the operating room.”

History of Tommy John surgery

At one point, a torn ulnar collateral ligament meant the end of a pitcher’s career. The condition rendered the thrower unable to pitch with the same control they had before the injury.

“This ligament is not strong enough for baseball to begin with; it was not intended for that,” Andrews said.

This all changed when then-Los Angeles Dodgers pitcher Tommy John was diagnosed with a torn UCL in the midst of the 1974 Major League Baseball season. This was supposed to be the end of his career. Instead, it saved it.

John’s surgeon, Dr. Frank Jobe, performed the first reconstruction of the UCL, using a procedure he devised through harvesting a tendon that would become the new ligament through a 3- or 4-inch incision made on the elbow. Holes are then drilled in the bones where the UCL normally attaches. The graft is sutured through the holes and tightened into position.

This has since become known as Tommy John surgery, as it rescued John’s career. John went on to pitch 14 more seasons — winning 164 games in that span — after a year off for recovery and rehabilitation.

Since then, the procedure has exploded in popularity among amateur and aspiring pitchers, many in high school or college and some as young as 10. According to a public dataset, the number of Tommy John surgeries performed on those under 21 in the United States was fewer than 10 from the surgery’s invention up until 2003. By 2017, at least 80 were being performed on that same age group per year.

Youth baseball and arm problems

MLB began tracking pitch counts as an official statistic in 1988 as a way for teams to better measure when a pitcher’s performance will start to fade.

In 1999, Andrews made an official suggestion of 100 pitches as a ballpark figure for when an arm tires per pitching outing at the major-league level. By 2014, ESPN began displaying pitch counts on-screen during televised games.

One year later, the National Federation of State High School Associations held a joint meeting with the Sports Medicine Advisory Committee and USA Baseball’s Medical Safety Committee to discuss pitch count limits due to further arm concerns beginning at the adolescent level of play.

Douoguih said he has performed a UCL repair on a patient as young as 10. The boy’s father had instructed him to throw curveballs before his arm was fully developed.

“It's so important to educate families about what the risks are,” Douoguih said. Andrews and Douoguih have had to turn down doing the procedure on certain patients.

“I had a kid come in. And his parents said, ‘Hey, can you fix little Johnny's arm?’ And I asked them ‘When did he hurt it?’ And they said, ‘Well, he didn't hurt it. We just heard that Tommy John surgery can make them throw faster,’ " Douoguih said. "And so I looked down at my watch, and I was like, ‘You got 10 minutes. I'm calling Child Protective Services, you guys better be out of my office.’ ”

Tommy John surgeries, or full UCL reconstructions, begin as early as in middle school for some pitchers. Dr. John Conway, a sports orthopedic surgeon and former head team physician for the Texas Rangers, said his youngest Tommy John patient was 14. Andrews mentioned a sixth-grade patient.

“When you do it on a 14-, 15-year-old, it's a lot of surgery and recovery for a young kid to have to go through,” Andrews said.

UCL reconstruction has also frequently begun to occur at the high school level all over the U.S.

Former Lufkin (Texas) High School varsity baseball player Brigham Hill underwent Tommy John surgery when he was 16. By 13, Hill was already throwing in the high 80s and was considered to be one of the hardest throwers in the state for his age. By 10th grade, he was pitching over 90 mph, but he noticed something wrong with his elbow.

“I was wishing I could get this looked at because at the time I was starting to get looked at by college scouts and pros scouting me around,” Hill said.

Hill played under then-Lufkin head coach Clay Berry, who also served as the special teams coach for the school’s football program. But when the starting pitcher approached Berry about wanting to get his arm checked out, hewas instead encouraged to go to his high school trainers.

Wanting a second opinion, Hill and his family went to Conway’s office. His UCL was torn — he needed Tommy John surgery.

“Berry and the other coaches put me in a corner,” Hill said. “ ‘Well, we're going to have to tell the scouts about all this.’ And they're just making little threatening remarks like that."

Berry did not respond to four requests for comment.

Hill added that the coaches told him going to their in-house trainer should’ve been sufficient.

“It's a scary time when you’re a high school kid trying to get recruited,” Hill said. “The last thing you need is high school coaches running their mouths.”

Following Hill’s time as a baseball player with Texas A&M University, he went on to pitch in the Washington Nationals minor league system. His career ended in 2020 when he voluntarily retired.

As for Lufkin High School, Berry's assistant coach, John Cobb, has since taken over as the head coach. He says he sees himself as a combination of old-school and new-school coaching.

“Pitch counts are for dumbasses, for people who don't understand how the body works and don't understand how to ramp kids up,” Cobb said. “An example being we had a kid one time that went out and threw 131 pitches in a baseball game … Next day, the kid’s out long tossing from foul pole to foul pole. That kid was a phenomenal athlete."

Baek family quickly embraced baseball

When 13-year-old Sang Ho Baek was told he was moving from South Korea to the United States, he had one question for his parents: “Can I keep playing baseball there?”

The family moved to Salisbury, Maryland from Seoul in 2014. Seong Han Baek, the pitcher’s father, spoke little English but memorized an introduction to make sure his son got back on the baseball field.

“Can my son play on your team?” Seong Han asked Little League coach after Little League coach. “His name is Sang. He is a pitcher.”

The father cycled from baseball field to baseball field, saying his rehearsed English phrase to every Little League coach he could find. Eventually, Fruitland Little League was able to find room for the eager child with a strong right shoulder.

Sang kept playing and playing. From Little League, to travel ball, to summer ball and showcases. He was a proud member of Canes Baseball, one of the top travel and showcase organizations in the country.

Sang made the James M. Bennett High School varsity baseball team as a freshman. He later would help the Clippers to their 2019 state title, throwing seven strikeouts and the final out of the championship game. In 2020, he was named to the Maryland Preseason All-State Team.

But during his senior year of high school, the pain started. By this time, Sang had also earned a scholarship to pitch for Division I George Mason University, a member of the Atlantic 10 Conference.

Most college freshmen do not see action on the pitching mound. Even while battling pain, Sang made seven appearances during his first year out of the bullpen.

Connor Lefort, a childhood friend and former catcher for the pitcher, said Sang was a gifted pitcher.

“He definitely wanted to play professional baseball,” Lefort said. “He had a good shot.”

When the pain became too much, the family sought out Douoguih. Sang was officially diagnosed with a torn UCL — he needed Tommy John surgery. Douoguih performed it, opting to take the graft from Sang’s hamstring.

But immediately after surgery, Sang had intense pain in his hamstring. Over the next few days, the pain wasn’t going away, even with the prescribed pain medication. After Sang’s surgery, Seong Han said his son told the doctor’s office he was still experiencing pain in his leg.

Conway said, generally speaking, in avoiding cases of pulmonary embolism, it is vital to take pain complaints seriously.

“When we're taking care of young people, we try to be vigilant in all my post-operative measures,” Conway said. “When people call up and say, ‘Hey, my [leg] really hurts,’ we set up for an ultrasound study.”

Sang recovered, watching TV on the couch alongside his sister. Hours after a Harry Potter movie marathon, Sunny went to Sang’s bedroom to check on him. She found him unresponsive.

“I ran upstairs, screaming,” Sunny said. “ ‘Dad, you need to come downstairs.’ ”

Sang was taken to the Tidal Health Hospital Emergency Room.

But he was pronounced dead on June 12, 2021, and a private autopsy was conducted. The official cause of death, according to medical records, was pulmonary embolism.

“When everything came out, people were writing us letters,” Sunny said. “Lawyers were writing us letters saying this wasn’t right. Saying we had to look into it.”

Douoguih said it is important to remember going into every surgery that a life is at stake.

“You just have to be careful because every person you operate on is a human life. It was something that I hope no surgeon ever has to go through,” Douoguih said.

Lefort said Sang’s family couldn’t stop staring at the pitching mound after his death.

“When we went to the ceremony George Mason did, his dad just stared through the fence at the bullpen mound,” Lefort said.

Despite trends showing the rise in the number of Tommy John patients, Seong Han says he is hopeful another death from this surgery will not occur.

According to Baek’s former medical malpractice attorney, Robinson Rowe, the origin of Sang’s blood clot is unknown. Rowe dropped the case because he didn’t think he could prove liability.

On June 26, 2021, at the Holloway Funeral Home in Salisbury, Maryland, an open-casket visitation was held. Even in death, Sang was a baseball player.

Citing respect for the Baek family, Douoguih declined to comment on why he attended the visitation.

Medical perspective on surgery

All three surgeons interviewed referenced the necessity of having the surgery, as most of the athletes would have difficulty completing basic tasks with the injured arm, never mind pitching.

Through time, Tommy John surgery has evolved through the grafting process. The ligament most often harvested is the palmaris longus tendon of either forearm.

“There’s no question that the palmaris tendon is the best, safest choice,” Conway said.

The next-most common graft comes from the hamstring tendon. Patients refer to this option as more painful and more difficult to navigate post-operation, according to Yankees AA-affiliate pitcher Derek Craft.

“My knee and hamstring were more uncomfortable than my elbow,” Craft said. “Just something simple as standing up in my chair was difficult or painful at times.”

More recently devised, another graft has begun being taken from the big toe extensor tendon. There is also forgoing using a graft at all and instead using a form of medical tape.

Very common on professional baseball level

All professional levels of baseball see Tommy John surgeries every year. Most teams have staff designated to work with the arm health of their athletes, making the process easier on the professionals than younger players.

New York Yankees relief pitcher Clay Holmes had his Tommy John surgery when he was 21 in 2014, returning to the mound the next year. Prior to entering the majors, he pitched across all four levels of minor league play, including for the Gulf Coast League Pirates.

Holmes said getting his Tommy John surgery while at the professional level of play comes with its advantages.

“The trainers are trying to make it go as easy as possible,” Holmes said. “It’s definitely a good feeling. I still remember my first outing back after Tommy John, my first start. ”

A MLB physical therapist and rehab coordinator, who has asked to remain anonymous, has seven years of experience at the major-league level and served in the same position in the minors previously.

The trainer said as a result of the increase in arm injuries, MLB has begun having rehab coordinators compile data specifically on the Tommy John surgery rehabilitation process.

“Anytime you do a Tommy John rehab now, they asked me to fill out trackers,” the MLBtrainer said. “When did he start strengthening? When did he start throwing? When did hestart off the mound? All these indicators.”

Those are heavily focused on range of motion and strengthening, according to Sean Kennedy, a doctor of physical therapy and board-certified clinical specialist in sports physical therapy at Memorial Hermann Rockets Sports Medicine Institute in Houston.

While MLB officials have implemented tracking measures for their players, theyhave also begun looking into tracking the number of youth Tommy John surgeries.

“[The MLB is] addressing the youth population because we look at these players now,and a lot of these athletes have already had Tommy John,” the trainer said. “They'retrying to focus efforts there, because if you've had a ton of previous injuries along theway, then it's probably going to lead to more injuries while you're at this level.”

Tommy John alternatives

There are alternatives to Tommy John surgery.Platelet-rich plasma injections are a form of regenerative therapy that uses a concentration of a patient’s own platelets to accelerate the healing process of injured tendons, ligaments, muscles and joints.

The injections are prepared by taking blood from the patient and spinning it down via centrifuge toconcentrate the platelets. These activated platelets are then injected directly into the injured area.

Conway said he has not seen any data verifying the success rate of PRP injections on his patients.

“We can offer biologic injections, but, quite frankly, biologic injections have not really been shown to be a solution for us,” Conway said.

Aaron Leathers, a former pitcher for Randolph-Macon, tells a different story. He said he immediately felt the positive effects post-PRP injections.

“It just kept getting better and better,” Leathers said. “I played for the Rockingham County Diamondbacks that summer. I was really able to let that elbow heal as much as I could. I was throwing harder than I've ever thrown before.”

Leathers is not the only pitcher who has made the decision to pitch through the injury, with MLB pitchers Seth Lugo and Masahiro Tanaka following suit.

Conclusion: Where do we go from here?

A dogwood tree near Spuhler Field was selected by Baek’s family and planted near the diamond at George Mason University by the Patriots baseball program in a ceremony honoring Sang’s life.

“The tree tells us that Sang truly loved baseball. He loved the mound, which was his dream,” his father said. “Although he stopped his journey for his dream in this world, please remember he will always look over us from that tree, wishing you and me to keep striving for our dreams.”

The official number of Tommy John surgeries performed nationally and internationally is unknown. But they are increasing, especially among youths, and the risk persists.

“If you can prevent these injuries from occurring," Douoguih said, "you're going to lower the risk of aterrible event like what happened to Sang Ho Baek.”