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“Laws of physics apply to the human body,” House said. “When the energy gets to the elbow and the elbow isn’t in a position to deliver the forearm, the elbow is what pays the extra price.”

Dr. Neal ElAttrache, the Los Angeles Dodgers team physician, sees velocities increasing (Strasburg averaged 97.3 mph on his 620 fastballs for the Nationals last season), without corresponding improvement to poorly conditioned core muscles. Significant elbow stress can follow.

Altchek compares the additional force to a golfer using a stiffer club shaft to carry the load of a more powerful swing. But a pitcher’s elbow can’t compensate for the increased load like a new club shaft.

“Their ligament,” Altchek said, “is not necessarily bigger, stronger and faster.”

To repair a ruptured ligament, doctors follow much the same procedure Jobe used for John on Sept. 24, 1974. Today’s version is less invasive and takes around an hour. That has decreased recovery time from 12 to 18 months to nine to 12 months. Strasburg’s return to Nationals Park one year and three days after Dr. Lewis Yocum fixed his elbow, isn’t unusual or rushed. The extended recovery is required to wait for the grafted ligament to mature and gain the elasticity needed to handle the load of pitching.

Jobe’s great leap forward transplanted the forearm’s palmaris longus tendon, which helps wrinkle the palm, into the damaged elbow. The tendon has a higher tensile strength than the UCL, but isn’t necessarily better. Fourteen percent of the population doesn’t have the tendon; part of the hamstring is used then.

The new tendon is looped through holes drilled in bone. Altchek developed a “docking” method that shrunk the size of the holes and the number of times the tendon is woven through.

To simplify the procedure, the ulnar nerve usually isn’t relocated and muscles and tendons on the inside of the elbow are split, instead of detached, to reach the ligament.

A study Altchek contributed to in 2006 tracked 100 overhead-throwing athletes who underwent Tommy John surgery. Ninety percent returned to compete at the same level or better than before the injury. ElAttrache estimates 10 percent of Tommy John patients re-rupture their ligament, something fixed with a similar procedure.

“There always the chance of it happening again, but if you’ve never had it done before you think, ‘That will never happen to me,’ ” Zimmermann said. “Then all of a sudden it does.”

The surgery’s persistent myth is of the new ligament being a super-charged rubber band allowing pitchers to throw harder. Untrue, doctors say. Of nine random pitchers who had Tommy John surgery, six increased their velocity in the first full season after surgery. There weren’t dramatic jumps. Josh Johnson’s improved from 92.4 mph to 93.5 mph, for example. During six minor league rehabilitation starts, Strasburg’s fastball ranged from 92 to 99 mph.

A rigorous, structured yearlong rehabilitation program is one cause of a jump in velocity. Conditioning improves. Mechanics are scrutinized and improved (major league teams frequently - and discreetly - send injured pitchers and prospects to ASMI for biomechanical analysis, where 50 elements of their delivery are measured by frame-by-frame cameras and computers). And the gradual nature of the injury means they’re no longer pitching with a slowly failing ligament.

The leaves are changing color, but Strasburg feels as if he’s in the middle of spring training. He’s thrown 14 1/3 innings in the past year and struck out 25 batters. But his curveball, the last pitch to return after the surgery, is erratic. And his endurance still is building.

“This surgery is really a roller coaster. If you sit there and ride all the highs and lows, you’re never going to get out of it,” Strasburg said. “You have to look at one month at a time, instead of one day at a time.”

ElAttrache does 25 to 40 Tommy John surgeries each year. Yocum does about 50. Dr. James Andrews, who founded ASMI, performs even more. Same with Dr. Tim Kremchek. One surgery each month is a significant number.

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