Shohei Ohtani vs. Brock Purdy UCL Recovery Timelines

A very serious, not at all humerus elbow injury comparison

On August 23rd, Shohei Ohtani was removed a from a game for what was then described as “forearm tightness.” This is often the first symptom of an ulnar collateral ligament (UCL) injury, and news soon confirmed it. Today, it was announced that Shohei Ohtani had a procedure to repair his UCL, and while the exact details are still unknown, both Ohtani’s agent and his surgeon confirmed that he will not pitch again until 2025. As a San Francisco Giants fan, I am saddened to hear that he won’t pitch for the orange and black in 2024, but I still look forward to watching him hit titanic moonshots into the ocean. (Please sign him for all the money, Farhan!) However, as I think about the recovery timeline for Ohtani, I question why Brock Purdy, a Bay Area Legend in his own right, could return from his own UCL surgery in less than six months despite significant similarities to the procedure Shohei Ohtani just underwent.

For more background on Mr. Irrelevant, he tore his UCL on January 29th, but waited 40 days for the swelling to subside before he had his surgery on March 10th. Purdy returned to action just over five months later for a 49ers preseason game on August 19th. What is so different between the situations for Shohei Ohtani and Brock Purdy where one will return to competitive throwing at 19 months, and the other did so at 5?

In short, pitchers often elect Tommy John surgery because their injuries are the product of gradual degradation of the ligament. These surgeries require longer recovery times for the new tendon to completely integrate with the damaged ligament and return it to full strength. Quarterbacks can return to action faster because they can elect a procedure to attach a manufactured brace across the damaged ligament to provide stability. Below I’ll break down the factors that lead to UCL overuse injuries, including workload, intensity of force through the elbow, and the difference in mechanics between the two throwing motions. These same factors contribute to the decision to elect for Tommy John surgery and an extended recovery timeline vs. a UCL repair with a brace and an expedited recovery timeline.

Pitchers vs. Quarterbacks UCL Stress Comparison

In Brock Purdy’s case, his UCL injury was sustained as a result of direct impact in a vulnerable position. This is not the typical mechanism for UCL injuries. In general, overuse leads to the tearing of the ligament, and unlike with muscles, ligaments and tendons don’t heal on their own with time. This is the mechanism for Shohei Ohtani, who stressed his ligament over time to the point where it requires outside intervention to heal. Let’s examine how the volume of work and the intensity with which they throw might impact UCL integrity.

Volume of Work

So let’s break down Ohtani’s workload and compare it to Purdy’s. According to data tracked by Baseball Reference, Shohei Ohtani has averaged 2,245 pitches per season over the last three seasons. He’s pitched in an average of 24 and 2/3 games per year over that stretch, and threw more than 80 pitches on 61 occasions. Through absolutely no fault of his own, Shohei Ohtani has missed the playoffs every year during that stretch, so each season has only been six months long.

For comparison, Pro Football Reference shows that Brock Purdy only attempted 170 passes last year over the course of nine games. However, he only started five of those games, so despite the smaller sample size of two games, the 27 passes per game he’s thrown to start this season is a more realistic figure to extrapolate over a 17-game slate. Using this figure, we can expect Brock Purdy to throw approximately 459 passes on the year. Purdy’s regular season only lasts four months, but ideally his season will be six months long to include the 49ers inevitable Super Bowl run.

I hear what you are saying: “But what about practice reps?” To which I will quote Ted Lasso quoting Allen Iverson: “We’re talking about practice. Not a game! We’re talking about practice.” However, it’s a valid point. Ohtani will typically take two days off after his start, followed by a light throwing session a couple days before he’s next expected to start. Brock Purdy, however, (barring injury) will throw in practices on Wednesday, Thursday, and Friday in the lead up to the game. To give Purdy the benefit of the doubt, we’ll project that he goes through a full game workload every practice, which would increase his throw count to 1,836 over the four-month regular season. That figure is much closer to the 2,245 that Ohtani has averaged over the last three years, so there must be other factors that contribute to the difference in UCL injury rates between pitchers and quarterbacks.

“Speed kills.” – Al Davis

Contrary to what many of us are taught growing up, studies show that the strongest predictor for whether a pitcher will require a UCL repair over the course of their career is their pitch velocity and the percentage of fastballs they throw. (Keller, et al. 2016, Coughlin, et al. 2019, Kriz, et al. 2022) Shohei Ohtani has been one of the best pitchers in baseball due in large part to his exceptional velocity. According to Baseball Savant, Ohtani threw his fastball at 96.8 mph, and his maximum velocity on a fastball this year was 101.2 mph. Again, according to Baseball Savant, this ranks him as the 3rd hardest throwing pitcher among those who threw at least 2,000 pitches this year. The fact that there are two players ahead of him on this list is absurd, and Ohtani is just another (albeit monumentally important) data point in the stunning jump in average velocity over the last four years coupled with significantly increased injury rates. According to Tom Verducci of Sports Illustrated, pitches of more than 100 mph more than tripled between 2019 and 2022, and have continued to rise in 2023. Data collected by Spotrac show that pitchers accounted for 59.38 percent of the total number of players who missed time across MLB in 2023, and 70.63 percent of the days spent by players on the injured list. When compared to 2019, these numbers represent an increase of 4.22 percent and 4.59 percent respectively.

These data shows an emerging trend. Pitchers are throwing as hard as they can on almost every pitch, and as velocities increase, so do injury rates. Pitchers are always throwing the ball 20 yards, and teams are encouraging them to push their bodies to the limit for maximum effectiveness.

In comparison, quarterbacks are not asked to throw with maximal effort as often, and they don’t require it for maximum effectiveness. This year, Brock Purdy’s average depth of target is only 8.5 yards downfield, and while this is lower than the total distance his passes travel, he rarely throws the ball as hard as he can. Instead, quarterbacks are asked to throw “touch passes” over defenders and screen passes along the line of scrimmage much of the time. Pro Football Focus reports that 11.6 percent of Purdy’s throws had a depth of target at 20 or more yards downfield. If we consider these the “maximal-effort” throws, then over the course of the year, we can expect him to make 213 such throws. This figure isn’t even 10 percent of Shohei Ohtani’s average of 2,245 throws on a per year basis. Even if we’re only counting Ohtani’s fastballs as his “maximal-effort” throws, Baseball Savant has his fastball percentage at 36.8 percent, and those 791 this year alone greatly outnumber what we can expect from Purdy.

Every High School Athlete’s Nemesis: Mechanics

I won’t focus on the impact of proper mechanics here, but instead will focus on how the differences in the throwing motion between pitchers and quarterbacks stresses different areas of the arm. Quarterbacks wear pads, and the ball is much heavier, so quarterbacks tend to sling the ball across their body, creating greater rotation from their hips and torso, and relying more on their pectoral muscle. This motion creates more stress on the shoulder, and as many as 71 percent of quarterbacks at the NFL combine reported shoulder injuries in their career. (Kirsch, et al. 2018)

In comparison, pitchers throw the ball from a much higher release point. Pitchers throw downhill and spin rates have become a point of emphasis league-wide, so pitchers are trying to pull down on the ball as much as possible. Muscles and ligaments are responsible for holding the joint together, and when muscles are stretched to their limits, it makes contraction more difficult as described further by Web MIT. In an overhead throwing motion, the higher the release point, the greater the stretch on the biceps, one of the muscles responsible for controlling movement at the elbow. Additionally, in a pitcher’s motion compared to that of a quarterback, the palm is rotated away from the shoulder toward the target throughout the acceleration phase. This is where the stress on the elbow is greatest, (Kriz, et al. 1985) and by rotating the palm away from the shoulder, the forearm muscles are also lengthened. The biceps and forearm muscles are further lengthened as the elbow extends at release. In a vacuum, this isn’t a cause for concern, as the human body is designed for this kind of exertion. However, as a pitcher fatigues, the muscles, which are already compromised by their length, are no longer able to properly control motion at the elbow, leaving the UCL as the last line of defense.

As previously stated, pitchers are generating velocities unlike ever before, and as a result, the forces through the mechanically-challenged elbow are creating injuries in pitchers that you rarely see anywhere else. Additionally, they’re throwing with maximal-effort more often than quarterbacks, and this is why they are fatigued and at much higher risk for UCL (and other arm) injuries. It is for this reason that starting pitchers are throwing fewer pitches than before, and why pitch count has become an enormous factor in the modern game.

Differences in Surgery Type Dictate Differences in Recovery Time

We’ve now established that pitchers need much more stability in their elbow in order to stand up to the additional stress created by repetitive maximal-effort forces, so let’s look at the different procedures Brock Purdy and Shohei Ohtani had to recover from their injuries.

UCL repair with InternalBrace augmentation

According to interviews done with Kyle Shanahan published by ESPN, the 49ers didn’t know whether Brock Purdy could have this procedure done until his elbow was open on the operating table. If there was too much damage to the UCL, then Tommy John and its extended recovery timeline would be the only option. However, Purdy’s injury wasn’t severe enough to mandate Tommy John, and the repair was done with an additional structure created by Arthrex called the InternalBrace System. This structure is anchored to each end of the ligament, and the additional stability allows the athlete to pursue a more aggressive rehabilitation program and subsequent return to competition sooner than a Tommy John recipient. However, this procedure is only available for those who suffered an acute injury like the one Brock Purdy did, and isn’t possible for those with degenerative injuries.

Tommy John Surgery

Long the gold standard of UCL repair, Tommy John was the first recipient of the eponymous surgery in 1974. Since then, there have been many new techniques to increase efficacy and reduce complication rates, but in general, a tendon graft is taken from somewhere in the forearm, foot or hamstring of the patient, and sutured onto the damaged ligament. The ligament needs time to fully heal, and then the athlete can begin building their strength again. Tommy John surgery often comes with a 14-month recovery timeline, and a lot of this is due to the length of time required to heal then regain strength, but pitchers often report that strength returns faster than control. Refining control might lead to longer recovery times despite the return to full (or even stronger) functionality.

Shohei Ohtani had a traditional Tommy John surgery in September of 2018, and was only able to pitch in two games for the Angels in 2020, despite the initial timeline suggesting he’d be available as a pitcher for the start of the 2020 season. However, he then began his recent run of dominance on the mound starting in 2021. According to his agent, Nez Balelo, the repair that was done in 2018 is entirely intact, and that this issue is taking place in a different area of his UCL.

What’s next for Shohei Ohtani?

They say that history repeats itself (don’t ask me who “they” are), and the story begins the same way this time around. It’s September, and Ohtani has undergone his UCL repair. Initial timelines indicate he should be able tco pitch again in 2025.

This time, however, the repair is slightly different. It appears Ohtani has also received an InternalBrace System, or something similar to it. According to Ohtani’s surgeon, Dr. Neal ElAttrache: “The ultimate plan after deliberation with Shohei was to repair the issue at hand and to reinforce the healthy ligament in place while adding viable tissue for the longevity of the elbow. I expect a full recovery, and he’ll be ready to hit without any restrictions come opening day of 2024 and do both (hit and pitch) come 2025.” So despite the additional structures put in place, Ohtani is still expected to have the same recovery timeline as he did in 2018.

I am not a physician, and like most other people who’s opinion you’ll read on the internet, I don’t have all the facts. However, it appears that Ohtani had something of a hybrid procedure between a traditional Tommy John and a repair with a brace. “Reinforcing the healthy ligament” sounds like a brace was put in to give him enough stability to hit in the upcoming season, but these braces alone can’t stand up to forces during pitching, so by “adding viable tissue” it sounds like there is a traditional Tommy John component that will require the extended recovery for him to resume pitching again.

Final thoughts

It’s an unfortunate reality in all sports, but injuries happen. In the cases of Shohei Ohtani and Brock Purdy, the mechanism of injury and subsequent procedure to repair the same ligament had vastly different impacts on their return to the field. I look forward to seeing Shohei Ohtani pitch again in 2025, and I’m glad that we’ll get to see him hit for the Giants in 2024, because he is the best athlete on earth (yeah I said it). Until then, Go Niners!