When Tommy John underwent the revolutionary surgical procedure on his left elbow in 1974 that would become his namesake, it was a desperate measure to save a valuable pitcher's major league career.
More than 40 years later, it has become commonplace for an injury that has reached epidemic proportions at all levels of baseball.
The son of the former pitcher finds it alarming that the surgery synonymous with his father's name is most often performed on players in their teens.
Dr. Tommy John, a chiropractor who grew up in South Florida but runs a performance and healing center in San Diego, cites a study showing that athletes ages 15 to 19 account for 57 percent of Tommy John surgeries as motivation in writing a book aimed at curbing the trend.
"It shouldn't be necessary," John, who wrote "Minimize Injury, Maximize Performance" as a sports parents survival guide, says of teens going under the knife. "The success rate after Tommy John surgery is not good. You don't want this surgery, especially if you have it in your teenage years."
While the focus has been on the rise in major league pitchers undergoing Tommy John surgery — about 25 percent of all active MLB players have — the eye-opener came with the 2015 study published in the American Journal of Sports Medicine showing the greatest number of procedures in the age 15-19 group — and the rate is increasing at an average of 6 percent a year.
To John, the revelation is a reflection of a larger problem of injuries skyrocketing in youth sports throughout the country during the past 20 years.
Notably, another study showed the number of soccer-related injuries treated in emergency rooms increased 78 percent from 1990 to 2014 in ages 7 to 17.
Specialization leads to injuries
In South Florida, Drs. Randolph Cohen and Eric Eisner have observed the trend in their U18 Sports Medicine practice at Joe DiMaggio Children's Hospital in Hollywood.
They attribute it to the increased emphasis on kids specializing in a single sport at a younger age and being pushed to perform on travel teams and to pursue college scholarships and the elusive dream of a pro contract.
"The biggest issue is that there's an overall kind of irrational push by parents on children who are playing sports for such long hours and such long durations and such great repetition that we're seeing an increase in the injuries in children than say we saw 20 years ago, where injuries like that were much more rare," Cohen said.
"They just can't take that repetitive type of consistent pounding on their bones, joints and ligaments without developing an inordinately high rate of injury that ends up ending their career and curtailing what they are capable of doing."
The common thread, regardless of the sport, is overuse of young muscles and ligaments that lead to injuries of varying degrees.
"We see a lot of knee injuries, ankle pain, back pain. Back pain is a very common overuse injury. You pick the body part, we've seen the overuse injury," Eisner said. "It depends on the sport and what the child is focusing on.
"Some gymnasts we're seeing are 5, 6 with overuse injuries. Ballet dancers and cheerleaders come in with a lot of overuse injuries."
Such injuries don't necessarily lead to surgery, but they can be debilitating.
Cohen said he rarely sees teenage ballplayers with elbow injures severe enough to require Tommy John surgery.
The oft-cited 2015 study showed the overall average incidence of Tommy John surgery in the database of athletes from recreational to big-league levels was just under 4 per 100,000 patients. But for the 15-19 age group it was 22 per 100,000 patients, which the study's authors termed "a staggering statistic."
Myths surround Tommy John surgery
Andrews Sports Medicine, the premier orthopedic center in the country headed by Dr. James Andrews, charted a meteoric rise in Tommy John surgeries performed on youth and high schools players beginning about 1994.
In a FAQ for Pitch Smart, an MLB and USA Baseball initiative that provides guidelines to help parents, players and coaches avoid overuse in young pitchers, Andrews said it is a myth that Tommy John surgery enables pitchers to throw harder than before they were injured.
Andrews attributes belief in the myth to an influx of parents with pitchers as young as 14 who come to him wanting Tommy John surgery without having an elbow injury to warrant it.
"The problem we're seeing at all levels is that players think that they can have this procedure and have a bionic arm," Andrews said in the Pitch Smart video. "If they do throw harder it's not because of the surgical procedure. It's because of the maturity of that player and all the rehab and conditioning that they do for a year or a year and a half in their comeback."
Andrews goes on to say, "If you're operated on in the eighth or ninth grade for Tommy John's procedure, your chances of reaching the collegiate level go down about threefold."
Andrews said in a 2015 interview that he went from performing surgery on one or two high school players in 1997 to now 80 or 90 a year.
Among them, Jesus Luzardo, who was a standout senior pitcher for Stoneman Douglas High when he blew out his elbow while throwing a pitch against Coral Springs High in 2016.
So far, Luzardo is one of the success stories of the reconstructive procedure. He's currently rated as the Oakland A's No. 2 prospect and playing for Double-A Midland, where he was 4-3 with a 3.08 ERA and 1.12 WHIP after 11 starts this season.
"It definitely took the wind out of your sails," Luzardo said. "That happened, but I've said, God has a plan for everything and I'm glad it happened because I'm in a good spot today, thankfully."
The surgery pioneered by Dr. Frank Jobe involves replacing a torn or ruptured ligament in the elbow known as the ulnar collateral ligament with a tendon from another part of the body.
Luzardo said the operation is just the first step in a long process. The key to returning to the mound is in adhering to the arduous rehabilitation guidelines.
"(Andrews) said, if you follow this rehab program the way we lay it out, the success rate is pretty high. But if you stray from that you could hurt yourself again or worse," Luzardo said. "I think it took me 14 months before I got on the mound for a real game. It's just long and tedious."
Success after surgery varies
Tommy John was 31 when Jobe fixed his elbow in 1974. He went on to pitch 14 more seasons, winning 20 games three times.
There have been notable success stories in pitchers regaining prominence, such as Stephen Strasburg of the Washington Nationals. But there is no guarantee of making it back or of enduring success after surgery, as former New York Mets right-hander Matt Harvey's struggles show.
Josh Johnson, one of the most promising young pitchers in Marlins history, had Tommy John surgery three times before giving up in 2017.
In his book, John noted: "Although my dad fully recovered, only 20 percent of those who have it ever make it back to their previous level of performance. Worse yet, between 25 and 30 percent of athletes that undergo Tommy John surgery find themselves no longer able to play baseball two years afterward."
John Smoltz is the only pitcher so far to make it to the Hall of Fame after Tommy John surgery.
Smoltz made a point in his induction speech of addressing the problems in youth sports, saying: "I want to encourage the families and parents that are out there that this is not normal to have a surgery at 14 and 15 years old. That you have time, that baseball is not a year-round sport. That you have an opportunity to be athletic and play other sports. Don't let the institutions that are out there running before you guaranteeing scholarship dollars and signing bonuses (convince you) that this is the way."
Pressure from parents, youth sports industry
Eisner takes that message directly to his patients, and he also bears the badge of Tommy John in the scar on his own elbow.
He grew up in Los Angeles before the travel team era but pushed himself to play year round. He tore his UCL when he was 18 and had surgery while a college freshman.
"It was a big influence in my decision to go into pediatric orthopedics," Eisner said. "Looking back on it, I wish I had played more sports other than baseball."
Now Eisner can point to his own experience when he sits across from a 13-year-old pitcher with elbow pain and his family
"I can show them the scar, and I can say, 'I know what I'm talking about. This is where you're going, this is the road you're going down if you don't change the behavior that led you to this injury in the first place.' "
Bringing about that change of behavior is the objective of Dr. Tommy John's book, which debuted June 5. He offers his Tommy John Solution as a four-step program for enabling youth athletes to develop their bodies without breaking them down. It involves a comprehensive change in mindset and behavior, which he details as rethink, replenish, rebuild and recover.
John places blame for the youth sports injury epidemic on pressures from parents and the multi-billion-dollar youth sports industry that funnels kids into specialized year-round regimens through a gauntlet of travel and select teams, camps, tournaments and elite showcases.
He points out that the cost of participating at this level ends up exceeding by far the value of the college scholarships that many parents envision — but only a small percentage of teen athletes can obtain.
"There's more stress around what's going on in these sports than I find celebration," John said. "It should be fun. These are kids, not pros.
"My dad had to sit there at 31 years old and be like, man, my career might be coming to an end. What am I going to do? Now 10-year-olds or 15-year-olds are coming to a crossroads in their performance and health."
That is happening most often in warm-weather regions that facilitate year-round play. The 2015 study, "United States Trends in Medial Ulnar Collateral Ligament Reconstruction," found that players in the South are undergoing Tommy John surgery at a significantly higher rate than any other region.
Over 18 years of coaching high school baseball, Stoneman Douglas coach Todd Fitz-Gerald has observed that players now are geared more for performance through playing on multiple teams, without allowing time for general training and rest.
"I think kids pitch too much, and they don't do enough throwing to keep their arm in shape," he said, noting that a pitcher shouldn't step on the mound for a bullpen session before several weeks of throwing on flat ground. And that should follow a period away from throwing altogether.
"If you're a pitcher, you need that down time not only to rest but you need to strength-train too," he said.
Multisport athletes thrive
There is plenty of evidence to support that players are better off confining their sport to its season and moving on to other activities the rest of the year.
A study of 1,200 youth athletes conducted by Dr. Neeru Jayanthi of Loyola University found that early specialization in a single sport is one of the strongest precursors of injury. Athletes in the study who specialized were 70 to 93 percent more likely to be injured than those who played multiple sports.
As for the perceived need to focus only on one skill to reach an elite level, consider that 29 of the 32 first-round picks in the recent NFL draft were multisport athletes in high school.
Dr. Tommy John played on the junior varsity team at Westminster Academy in Fort Lauderdale when he father was coach there in the early 1990s. But it wasn't until his senior year, after the family moved to Minnesota, that he showed exceptional ability and was selected as the 1996 Gatorade Player of the Year in the state.
That was also the first time his father offered the benefit of his pitching knowledge in specialized instruction and began to show him how to maximize his ability.
"I would ask him, could we learn this pitch? He was like, no, we'll get there. We would just have a catch," John said of his father's approach when he was younger. "I'm very thankful for how I was raised. We all played different sports. I was slow to develop."
Speculating about what might have happened had his big-league father pushed him to emulate his own success, John said, "There's a chance I would have had an injury."