Athletes fear the day it all comes to an end.

Whether it is something they can control, or something they can’t, the thought of never playing a sport they love is unbearable and will often lead to rash decisions.

This was the case of Tommy John, who tore his ulnar collateral ligament during the 1974 season and heard his career was all but over. With just 11 years of the big leagues under his belt, the Los Angeles Dodgers southpaw knew it wasn’t time for him to retire, so he called Dr. Frank Jobe and told him to “make up something.”

With the pitcher’s approval, Jobe performed the first ulnar collateral ligament replacement surgery, which entails taking the palmaris longus, a superficial ligament in the wrist, and weaving it through drilled holes across the medial side of the elbow so valgus stability — which allows bending of the elbow — is re-established.

Patients receiving this surgery have two options— an autograft, which was used during the John procedure, or an allograft, which takes the ligament from a donor — most often from a cadaver.

Today, the procedure is commonly known as “Tommy John” surgery.

“The purpose is to restore the stability,” said Dr. Bradley R. Noon of
Georgia Sports Orthopedic Specialists in Gainesville. “Tommy John was told there was a 1 in 100 chance it might work and it might take two to three years to recover.”

John was back in the big leagues two years later at age 33 and pitched until May 25, 1989 when he was 46. During those 13 years, when he pitched more than 2,800 innings, won 170 games, had 972 strikeouts and a 3.26 ERA, John not only proved that the ligament replacement surgery saved his career, but it could save the career of any pitcher who suffered an elbow ligament injury.

This is still the case more than 30 years later.

“It saved my career,” said Atlanta Braves pitcher Tim Hudson, who had the surgery performed Aug. 8, 2008 by James Andrews, M.D. “I was prepared to hang ‘em up.”

But Hudson knew there was an option. Unlike 35 years ago, the right-hander could just schedule the surgery with a world-reknowned doctor and if he rehabbed according to plan, he’d be back on the mound in a year.

“That thought (of your career ending) creeps into your mind, but you understand the surgery is real successful nowadays,” Hudson said. “If this was 20 years ago, I might have been done for sure.”

Hudson’s injury was a lot like John’s in that it was a product of wear and tear, not from a one-time occurrence when the elbow “pops” and the ligament ruptures.

“It’s something we don’t see too often with kids, thank goodness,” Noon said. “Younger kids get ‘little leaguers elbow’ where they aggravate the growth plates more than anything. Luckily, they’re a little bit more resilient in not tearing up this ligament.”

But that doesn’t mean it’s not possible, and although Noon has never performed the procedure on anyone younger than 16, having to do so would cause a dilemma.

“You have to ask yourself, ‘Do I reconstruct this elbow and risk giving this kid a growth abnormality?,’” Noon said. “You kind of have to wait until they get older to do the surgery.”

The risk of a growth abnormality is only prevalent with pitchers younger than 17, and although there are risks of a faulty graft being used and infection, Tommy John surgery has a 90 percent success rate.

“The sad thing is there are some misconceptions out there,” Noon said. “There’s a few crazed baseball people who come in with a healthy arm and they want a Tommy John surgery because they think if you tighten the arm, they can throw faster.

“If you look at the people who have this surgery, they’ll come back better than they were before.”

Hudson is a prime example.

After an 11-month layoff from competitive pitching, Hudson had his first rehab start on July 19, 2009 in Myrtle Beach, S.C. Two months later, he was back with the Braves to close out the 2009 season and show the team he was ready to pitch in 2010.

“That’s one of the reasons I came back last year, not just to prove to them, but to prove to myself that I can or can’t do it,” Hudson said. “I definitely didn’t want to go out there and try and fool someone into signing me.”

Management liked what they saw, and after posting a 2-1 record in seven starts, Hudson signed a three-year, $28 million contract extension that includes a team option for the 2013 season.

“It’s one of those things where I have a lot of pride in what I do,” said the right-hander who turns 35 on Wednesday. “I don’t play this game for the money or the fame, I play because I love it. I felt like I was good for however long I want to play after last year.

“I didn’t feel like I was 100 percent, but I felt I was going to be,” he added. “I saw the light at the end of the tunnel; I knew that I wasn’t done yet.”

Hudson credits most of that success, plus his 8-4 record and career-low 2.44 ERA this year, to the health of his shoulder, which is a prime reason pitchers may require Tommy John surgery.

“Before I had my surgery, my shoulder was banged up a little bit,” Hudson said. “As a result, my range of motion was altered a little bit, which caused the elbow problems and I ended up needing Tommy John.”

Hudson said that “wear and tear” and “just getting older” caused the shoulder fatigue, and ultimately the surgery, but Noon believes several factors lead to ligament replacement.

First there’s the issue of pitch counts, and that recent studies have shown elbow problems occur more from repetition than types of pitches thrown.

“Overuse seems to be No. 1 on the list if you had to single one factor,” Noon said. “Those studies are with all-comers (kids who throw off speed and fastballs, just throw off speed and throw only fastballs) and across the board it shows it’s the number of throws that’s the most important. Kids who throw more than 700-800 throws in a season are high-risk.”

Playing on too many teams and not allotting time for rest are two more reasons a pitcher can develop elbow problems.

“I tell kids to prioritize which team is the most important,” Noon said. “The elbow’s like a set of tires, you only got a certain number of miles on it, so you gotta be careful how you use them.”

Regardless of the reason the surgery is needed, going through the rehabilitation process is arguably the most important aspect of returning back to original ability.

“You have to have patience, and I’m not a patient person,” said Hudson, whose rehab consisted of 80 percent shoulder workouts.

“You want to go out there and be ready in three months instead of 12 months. You just gotta know there’s goals to reach every couple of months and you want to get there in that time frame and not before.

“If you rush to get to that second level, come the fourth or fifth level, you might have a setback,” he added. “You take a year off, have major surgery on a ligament, you need the little baby steps along the way to get back to full strength.”

Andrews is famous for having a top-notch rehab program, which Hudson called “almost an exact science.” Noon, who has worked with Andrews in the past, uses the Modified Andrews Protocol for his patients and calls it “aggressive in a lot of ways, but conservative in others.”

The first three to four months of rehab are designated to the recuperation of the ligament, and patients aren’t allowed to start throwing until 10-12 weeks after the surgery, which can cost more than $15,000 plus rehab.

“There’s no throwing hard until 12 weeks minimum,” Noon said. “Before that, it’s counterproductive.”

Intense shoulder, wrist, elbow and biceps workouts follow, and in a year, most pitchers return and are capable of pitching at their previous level.

“I don’t know if it’s the surgery, but what gets guys back on track, and what gets guys’ careers back on track is the rehab,” Hudson said. “The rest you give yourself, the strength your shoulder gets from the rehab process, and you’re taking a year off.

“You’re taking a year off from pitching and doing nothing but concentrating on conditioning to strengthen your arm, and healing your arm, and you’re working out your body.

“You have a year to get in the best shape you possibly can be in.”

Noon agrees.

“Returning to prior level of play or better is a combination of rest, which allows them to heal and work on mechanics,” he said. “The fact they’re concentrating on rehab for a long period of time usually ends up putting them in a better spot than where they left off.”

For Hudson, the year off also provided an opportunity for reflection.

“It really was an eye-opener for me,” he said. “I was at the point of my career when I was 10 years in, I had small kids at home, and you start thinking what’s going to happen when I’m done. After the injury, it was like ‘whoa, this might be it.’

“After being away from the game, you realize that you do love it, I’m not ready to walk away yet,” he added. “It was great, it was a rejuvenation for my career.”