Baseball's medical revolutionary
Honored by Hall, Jobe's Tommy John surgery still prolonging pitchers' careers
30 for 30 Shorts: Tommy and Frank
There are currently 366 pitchers among all players on active 40-man rosters in Major League Baseball. If it weren't for Dr. Frank Jobe, the number of pitchers on MLB rosters would be reduced by roughly 25 percent.
The orthopedic surgeon and former Los Angeles Dodgers team physician conceived of the revolutionary procedure, now known as Tommy John surgery, that restores function to a thrower's elbow after the failure of a critical ligament. Named after his first patient, the surgery is now routine in the world of baseball medicine and has clearly prolonged the careers of numerous pitchers worldwide. For that reason, Jobe received special recognition for his contributions to baseball at the National Baseball Hall of Fame awards presentation in Cooperstown, N.Y., on Saturday.
"When you consider that almost one in four active pitchers in Major League Baseball have had a Tommy John operation, I don't think there is anyone who has changed the landscape of a sport more than Frank Jobe has for baseball," said Dr. Neal ElAttrache, a longtime partner of Jobe's at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles and his successor as Dodgers team physician.
During the Hall of Fame presentation, Jobe was joined on the stage at Doubleday Field by John, his patient and friend. At the evening receptions, Jobe was surrounded by family, including his wife, Beverly, along with their children and grandchildren. Hall of Fame legends introduced themselves to him, congratulating him and thanking him for all he has done for baseball.
Generations of surgeons who trained under Jobe, along with other sports medicine colleagues and research collaborators, traveled from around the world to show their admiration for a man whose influence, they believe, transcended the realm of sports medicine into simply the realm of sports. Among them were team physicians for professional and college baseball, football and basketball organizations along with others who treat recreational, high school and youth athletes.
Dr. Teruhisa Mihata, a shoulder and elbow surgeon who also conducts biomechanical studies, traveled from Osaka, Japan, to honor the mentor he has studied with for 10 years in the States. Even former Dodgers pitcher Chan Ho Park was present to see his former team physician recognized.
The gathering of Jobe supporters in Cooperstown was a reflection of how many he has touched in the worlds of sports and medicine. Considering the term "sports medicine" was just coming into use around the time of John's 1974 surgery, the trajectory of Jobe's now-famous procedure has followed that of modern sports medicine; remote concepts once associated only with elite athletes are now increasingly familiar to athletes of all ages and skill levels.
It might never have happened. Jobe didn't have aspirations of being a doctor. He grew up in Greensboro, N.C., and played a little bit of baseball as a child. "I wasn't very good," he says. Little did he know that his livelihood would forever link him to the sport.
He enlisted in the Army at age 18 and was placed in the 101st Airborne Division where he was assigned to medical supply. In addition to preparing supplies for his medical teams and putting his typing skills to use ("I kept good records"), Jobe spent a good deal of time watching the surgical teams he supported and would often help lend a hand mixing medicines. The doctors asked him what he was going to do when he got out of the service, and he had no idea. After all, he hadn't yet gone to college. When they suggested he should be a doctor, Jobe agreed.
When he returned home, he attended Riverside College, then went on to medical school at Loma Linda University. After a few years in private practice, Jobe embarked on a residency in orthopedics at USC. It was there that he met his business partner.
Dr. Robert Kerlan was an attending physician at USC while Jobe was a resident. When Kerlan invited Jobe to join him in practice in 1965, Jobe proudly says they made a handshake agreement. Kerlan's first patient for Jobe was then-Dodgers pitcher Johnny Podres. It was the beginning of Jobe's sports medicine practice and his introduction to the Dodgers.
Less than 10 years later, he would perform an operation on another Dodgers pitcher, one named Tommy John.
The surgery's origin
In 1974, John thought his days on the mound were over. In a game against the Montreal Expos on July 17, with runners at first and second and Hal Breeden at the plate, John threw a pitch that landed nowhere near the plate. John said of that moment: "I felt a pain I've never had before."
Jobe saw the pitch sail and John in pain. He examined John in the clubhouse immediately afterward and saw something alarming.
"I could open his elbow up to a 45-degree angle, and I figured the [ulnar collateral ligament] was gone," Jobe said. "At the time, they called the injury 'throwing the elbow out' and guys were sent home. And they didn't return."
In that era, if a serious injury threatened a pitcher's throwing elbow, he was likely replaced the following season. As John said, "You were toast after surgeries." Disappearing into the sunset with broken bodies and busted dreams, not able to see their careers play out the way they had envisioned, they could only watch as the next pitching prospects would come along to take their spot. Sadly, many felt they still had more baseball in them. They weren't old men yet, even by athletic standards, but their inability to consistently control the ball's location or velocity left them no opportunity for pitching. Most accepted their fate and yielded to the hand their bodies had been dealt.
Tommy John was not so accepting. At first, Jobe tried casting the elbow for eight weeks, hoping for scar tissue to fill in and allow John to throw. John could throw, but only at about 75 percent of normal. He tried to forcibly pitch through the pain, but the arm simply wouldn't cooperate. He turned to Jobe, who initially told him there was nothing more he could do. John responded by telling Jobe he did not want his career to end. He did not want to be sent home. He said, "Doc, you've got to come up with something."
Jobe thought about it and wondered if he could tap into what his colleague Dr. Herb Stark, a hand surgeon, was doing with tendon transfers to restore finger function to his patients. Stark would harvest a tendon from the patient's forearm and move it to the hand. Jobe wondered if he couldn't harvest the same tendon and put it where the failed ligament used to be to restore stability to the elbow.
He offered it to John as an option but cautioned him against expecting much: "I told him it was only about a 1-in-100 chance it would work."
But John's response was optimistic: "I told him a 1-in-100 chance is better than no chance at all. And without the surgery, I've got no chance."
As scary as it might seem to undergo a procedure never before attempted, John was not as nervous as he had been a couple of years earlier. In 1972, John had his first elbow surgery and feared he would never regain his form. He underwent a procedure with Dr. Jobe to remove bone chips and repair the flexor mass, the muscle group that bends the wrist and helps control grip.
The procedure was a success, and John returned to pitch in 1973. But John lacked confidence in his elbow, something he realized during spring training after he had an embarrassing tirade in response to frequent questions about his health. Jobe came to John's rescue with some simple advice.
"He told me, 'I can tell you your elbow is healed; there's nothing physically wrong. But that's all I can do. No one can convince you your elbow is sound but you,'" John said. "And then it clicked. I began to throw fine the next day and I never looked back."
That experience gave John not only confidence in his elbow, but also confidence in his surgeon. He needed both in 1974 when he agreed to undergo the first surgery of its kind, a reconstruction of the ulnar collateral ligament using a palmaris longus tendon graft.
On Sept. 25, 1974, Jobe performed the very first Tommy John surgery.
Then came the waiting. As he started to regain his motion after surgery, John noticed that something wasn't right. He was developing a claw hand as the fourth and fifth fingers began to curl downward, and he was experiencing numbness in those fingers. He also noticed weakness in his hand and couldn't hold a baseball properly to throw it. Perhaps the surgery wasn't going to work after all.
John didn't give up. He described what he felt to Dr. Jobe, who already suspected the ulnar nerve as the culprit. This is where John helped Jobe figure out the next step. John noticed if he straightened his arm outward, the symptoms relented. But as soon as he flexed his elbow, they worsened again. Jobe recognized the nerve was being restricted in certain positions. He explained to John that he would have to go into the elbow again to remove scar tissue from the area around the nerve.
Back they went into surgery, hoping this would be the final hurdle. Jobe freed up the nerve from adjacent scar tissue and transposed it to a slightly more forward location, where it would be less likely to be compromised. And it worked. The feeling returned to John's fingers, the strength came back to his hand and the claw went away. Now if he could just get back to the mound.
John and the Dodgers' athletic trainer worked diligently on a program with that goal in mind. John started by playing catch; he threw a little bit every day, checking in with Dr. Jobe regularly about what he had tried in practice, what he felt and whether it was easy or difficult. And Jobe would allow him to progress based on how his symptoms behaved. This would ultimately become the foundation for the rehab program following Tommy John surgery that exists today.
The ultimate test came one year and one day later, when John took the mound in a major league game. While Jobe had seen him throw throughout the course of rehab, this was different. While he wasn't nervous during either surgery, Jobe said he had "sweaty palm syndrome" watching John pitch.
"I had no idea if it would hold. I thought it might just snap off," he said.
Then came the first pitch. For starters, the ball went where it was supposed to go. And better yet, John didn't seem to be in pain. With each pitch, Jobe could relax a little more. It appeared as if the surgery just might hold up.
And did it ever! For 14 years after undergoing Tommy John surgery, the pitcher never missed a start. John won more games after surgery (164) than he did before (124). When he retired from the game, it wasn't because of his elbow. Yes, the surgery had worked.
A huge success
The success rate of the surgery has been so consistently high that an excellent outcome is expected rather than hoped for.
Dr. Wiemi Douoguih, the medical director for the Washington Nationals, has a unique perspective. Douoguih trained under Dr. Jobe and Dr. Lewis Yocum while at KJOC and participated, alongside Yocum, in quite possibly the most scrutinized Tommy John procedure ever. In 2010, the two performed reconstructive surgery on the elbow of Stephen Strasburg. Every second of Strasburg's progress was carefully monitored by the media, along with an attentive and expectant fan base that expected a successful outcome. Douoguih saw the experience as a positive.
"It's a testament to Dr. Jobe's brilliance that the procedure really hasn't changed much yet is so successful," Douoguih said. "And it's a testament to his humility that he projected such a small chance of success."
Depending on which medical study is cited, the success rate for a return to the playing field at the same level or higher following Tommy John surgery ranges from approximately 80 to 90 percent. The average time to return to throwing is approximately four months, and the average time to return to competition is just less than a year. Considering that Tommy John returned to competition a year and a day after surgery, the timetables have remained relatively stable and the success rate remains remarkably high.
Despite some modifications depending on the surgery, along with a few embellishments for improving overall training and conditioning, the infrastructure of the rehab program remains largely the same.
It's a testament to Dr. Jobe's brilliance that the procedure really hasn't changed much yet is so successful. And it's a testament to his humility that he projected such a small chance of success." -- Dr. Wiemi Douoguih, Washington Nationals medical director
Perhaps even more amazing is that athletes are not only returning to their prior level of play, but to a higher level of play. In a study of minor league pitchers conducted in 2012 by Stan Conte, the Dodgers' vice president of medical services, one in seven reported a history of Tommy John surgery. Of those who had undergone the surgery, 30 percent had it at age 19 or younger. While no one likes to see the trend of younger athletes succumbing to this injury, these results do illustrate that many athletes are moving on and performing at a higher level after surgery.
ElAttrache says Jobe's masterful surgical skill in developing a sound procedure has stood the test of time. "The treatment for this injury has become so predictable," ElAttrache said, "that a player coming out of high school can tear his ligament and before he gets it fixed can still get drafted with the confidence of knowing that if he undergoes the operation that Frank Jobe pioneered, there is an excellent chance this player will be able to not only return to his sport but get on the trajectory to becoming a great player."
It's worth noting that both Jobe and John are outspoken about the rise in ulnar collateral ligament injuries in youth athletes. Over Hall of Fame weekend, both expressed concern about year-round baseball play. As John said, "These kids and their parents want to be like the big leaguers. So I ask them, 'What does Justin Verlander do in the offseason? Does he pitch every day?' And the answer is obviously 'No.' Of course not. He rests. If one of the best pitchers in the league doesn't throw every day of the year, then obviously you don't need to throw every day of the year. It's common sense."
Jobe addressed the growing myth that having Tommy John surgery would make someone a better pitcher. "That's just not true," Jobe said. "Often times the athlete is spending his recovery time also working on his core, his shoulder, things that need to be corrected. And the athlete's performance was probably dropping off, including his velocity, just prior to getting hurt. So when he comes back he's better. That's probably because he's been in rehab, not because he had a performance-enhancing operation."
The next frontier
Will there be another Frank Jobe in sports medicine? Probably not. The magic combination of physician and patient and the introduction of a single procedure that will radically change a sport would be hard to reproduce. Not to mention the acceptance of risk.
"He gave a guy a 1-in-100 chance of success and then had the guts to come up with this procedure," Douoguih said. "If I gave someone a 1-in-100 chance today, he'd walk out of my office."
Many believe the future is not in surgery but in biologic therapies, a rapidly developing area of sports medicine that might preclude the need for more invasive procedures. Biologic therapies use the body's own natural elements to help heal injury. Platelet-rich plasma (PRP) injections involve drawing the athlete's blood and then separating it via centrifuge. The components containing growth factors integral to healing are concentrated and then re-injected into the injury site.
The idea is that overall tissue healing will be improved using the body's own blood product, and nothing synthetic. Baseball players are receiving PRP injections even as initial trials of treatment before going down the path of Tommy John surgery. The results so far are limited at best, but it is still early. Stem cells of various types are also being evaluated for their application in tissue healing and regeneration, but there are limitations to their use in this country due to federal regulations.
While the science is still young and there is debate within the medical field about the ideal parameters for treatment and even their overall efficacy, the world of sports medicine provides the optimal arena for developing these techniques. After all, where are the demands for improved healing at an accelerated rate while still delivering peak performance any greater? And what if those things could be accomplished without the use of synthetic drugs? This, many believe, is the next frontier of sports medicine.
Courageous and humble
Many of Jobe's peers acknowledge the courage it took to venture into uncharted territory, to try something on a highly visible athlete with no way to predict the outcome. The best thing he had going for him was an athlete who believed he could -- and would -- find a way to help him.
"The two of them went off into the unknown together," ElAttrache said. "Tommy with ultimate trust in Frank and Frank, being the great surgeon that he is, confident he could use that tendon and make it work."
Perhaps more impressive was Jobe being undeterred by the initial complications John experienced. As ElAttrache pointed out, others might have given up, not willing to take such risks again.
"He did that operation which left Tommy John with an ulnar nerve palsy, sensation loss and motor function weakness that took a while to recover from, and Frank still had the courage of his convictions," ElAttrache said. "He knew he was onto something and continued to make the operation better rather than abandoning it altogether."
The man considered the rock star of sports medicine, Dr. James Andrews, has only the highest praise for Jobe. Andrews, whose name is associated with so many high-profile athletes that he is as well known by sports fans as any of his patients, credits Jobe with mentoring him in the world of baseball medicine as well as mentoring others worldwide.
"His leadership has been instrumental not only in the development of the Kerlan-Jobe clinic and baseball physicians in the United States," said Andrews, "but also for expanding baseball medicine overseas, particularly in Japan and Korea."
While the respect for Jobe's contributions is universal, the admiration for Jobe the man is even greater. Consistently cited by his peers as a man of brilliance and humility, Jobe continues to serve as a role model for others in sports medicine. Look no further than the name of the surgery itself.
"Technically, it was the reconstruction of the ulnar collateral ligament using the palmaris longus tendon graft," Jobe said, "but that was just too much to say. It was easier to just say 'Tommy John.' Two first names. It just sounded nice."
In talking with Jobe, you get the sense he would have never considered naming a surgery after himself. Jobe even describes the Tommy John experience this way: "I did a little bit of surgery, but he [John] did all the hard work."
"Show me an individual who doesn't care who gets the credit and I'll show you someone who's highly successful," Andrews said. "Frank Jobe is the epitome of someone who has never asked to get credit for what he's done. But if there's any professional outside of baseball circles who deserves to be in the Baseball Hall of Fame, it's Frank Jobe."
The impact continues
Baseball fans can be thankful for the confluence of events that brought Jobe and John together. Speaking at the Hall of Fame awards ceremony, John thanked the Chicago White Sox for trading him, noting that were he not a Dodger, he would never have met Jobe and his career likely would have ended when his ligament failed him. Jobe credits John with being the perfect patient for an experimental procedure, noting John provided feedback throughout the entire process. John helped the Dodgers' athletic trainer, Bill Buhler, conceptualize what type of tools he would need to rehabilitate his weak hand after surgery and kept Jobe informed, in great detail, about his progress.
Show me an individual who doesn't care who gets the credit and I'll show you someone who's highly successful. Frank Jobe is the epitome of someone who has never asked to get credit for what he's done." -- Dr. James Andrews
Above all, the mutual trust between doctor and patient, something so highly valued yet so often hard to come by, enabled John and Jobe to form a partnership that ultimately contributed to the procedure's success. The model Jobe created, with John as his partner, has expanded exponentially ever since to touch the lives of numerous baseball players and those who treat them. Andrews calls Jobe the primary motivator and developer of baseball medicine and says Tommy John surgery is "the single most dramatic development in the history of baseball medicine."
The real impact is far greater. Fans have been treated to extended viewing of players whose time in the sport would have been drastically reduced were it not for Tommy John surgery. John Smoltz pitched for nine years after his surgery. A.J. Burnett is still pitching at 10 years out from his procedure. Adam Wainwright is having a career season in his second year removed from surgery. And imagine what would have been if the young phenom, Stephen Strasburg, did not have Tommy John surgery as an option? His career would have consisted of 12 major league games. Already, Strasburg has had more than four times as many major league starts since the surgery than he had before it.
There's only one simple thing to say to the man who forever changed baseball by being skilled enough to craft a procedure that transformed a career-ending injury into a career-extending result, yet humble enough to name it after his patient, not himself.
Thank you, Dr. Jobe. Thank you.