Tommy John elbow reconstruction surgery was once so rare that when the procedure’s namesake had it in 1974, many believed he’d never pitch again. Now, it’s so common that one doctor has performed three such surgeries on Major League Baseball pitchers in the past two weeks.

Orioles ace John Means became the latest, receiving the surgery Wednesday morning in Texas from Dr. Keith Meister. Orioles executive vice president and general manager Mike Elias called the surgery “successful” and said the club expects Means to return “at some point in 2023.”

“Everything went great,” Elias said.

It can take 18 months to come back from the procedure, so the road ahead for Means is lengthy. But it’s also a well-trodden path, as hundreds of hurlers have had the surgery and continued their careers. In 2021, about one-third of MLB pitchers were Tommy John veterans.

The surgery repairs a torn ligament in the elbow — the ulnar collateral ligament (UCL), which connects the humerus to the ulna — with a tendon from elsewhere in the body.

When John, a Los Angeles Dodgers lefty, tore his UCL and received the surgery for the first time nearly a half-century ago, it was radical and experimental. But because of increased pitch velocity and arm usage, especially in youth athletes, the injury and the surgery have become more common for pitchers, who repeatedly and violently snap their arm as fast as possible.

“Throughout everything human beings do on the face of the Earth, there’s almost nothing that puts that kind of stress in that location in your elbow,” said Andrew Cosgarea, an orthopedic surgeon at Johns Hopkins who served as the Orioles’ team physician from 2000 to 2010. “And that’s the crazy thing about throwing that round, white ball 100 miles an hour.”

Tommy John surgery remained a rarity for most of the 20th century, but by 2012, one in seven MLB pitchers had received it. In 2017, that figure had climbed to one in four, and as of last season, one in three had undergone the operation, based on data compiled by baseball analyst Jon Roegele.

Meister, Means’ surgeon, also performed the operation on two MLB pitchers (Luke Jackson and Deolis Guerra) on the same day, April 13, earlier this month.

Rico Garcia, who signed with the Orioles in the offseason, had Tommy John surgery more than a year ago and continues to rehab.

“It was a pretty easy decision to make just because it was torn so badly, there wasn’t much to think about it,” he said Tuesday.

But there was a time when a torn UCL made for a different, easy decision: retirement. It essentially ended the career of Hall of Famer Sandy Koufax in 1966.

A decade later, when John pitched in an MLB game a year and a half after a tendon in his right forearm had been moved to his left elbow, his Dodger teammate Mike Marshall, who was studying for a Ph.D. in kinesiology, called it “the greatest accomplishment I’ve ever seen.”

John, 31 at the time of the surgery, was named the National League’s Comeback Player of the Year and went on to pitch until he was 46 years old. He logged more seasons and innings after his surgery than he did before.

More success stories followed. David Wells had the surgery in 1985, and Hall of Famer hurler John Smoltz, Washington Nationals ace Stephen Strasburg, New York Mets right-hander and two-time National League Cy Young Award winner Jacob DeGrom and 40-year-old Adam Wainwright, pitching his 17th season with the St. Louis Cardinals, also excelled post-operation.

But misconceptions around the benefits of Tommy John are as old as the surgery itself.

“I know they had to graft a new arm on Tommy John, but did they have to give him Koufax’s?” opposing hitter Pete Rose joked in 1977.

“Whatever they did in that surgery room, baseball better hope they kept the blueprint,” famed sportswriter Jim Murray wrote at that time. “Some clubs would like to send their entire pitching staffs in for the operation.”

The surgery’s success in so many pitchers has led to the incorrect belief, by some, that the procedure can be advantageous to anyone — even to those who don’t have a torn UCL.

“That’s a misunderstanding of some patients and some patients’ parents,” Cosgarea said.

But the surgery can help only those who have a torn UCL. And it has its downsides; the recovery often takes more than a year, some pitchers don’t return as strong as they were before, and like any surgery, there are risks. In an exceptionally rare case, a George Mason pitcher who’d attended high school in Salisbury died last year following complications from Tommy John surgery.

Although Tommy John surgery only makes sense for throwing athletes (if the average person tore their UCL, it’s unlikely surgery would be needed), it’s not limited to MLB. A 2015 study found that 57% of those who undergo Tommy John are between the ages of 15 and 19 and more than 30 pitchers drafted in the 2021 MLB draft had already had the surgery.

The increase in Tommy John in recent years is primarily because of overuse — simply throwing too hard and too often — starting from a young age.

“This isn’t just something that happens in the major leagues,” Cosgarea said. “Problems start early on, and they’re cumulative.”

One of the youngest to ever undergo Tommy John surgery was Hayden Hurst, who received the procedure in eighth grade in 2008. A two-sport standout, he went on to become a 2019 first-round pick for the Ravens as a tight end.

In 80 to 85% of cases, Tommy John surgery is successful, meaning that a player returns to the level at which they previously competed. The recovery process typically takes 12 to 18 months, and throwing begins five or six months after the operation.

For Means, who was an All-Star in 2019 and remains under team control through 2024, that could mean a potential return would come midway through the 2023 season. But each player is different, both in their timeline and in their results.

Does Garcia, who received the surgery just over a year ago, now feel like the same pitcher he was before?

“We’ll see,” he said. “I mean, I think I’m the same. It’s just going out there and competing, working with what I got.”

Baltimore Sun reporter Nathan Ruiz contributed to this article.

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