Tommy John Surgery: Treating Elbow Injuries in Athletes

Spring is here and that means little league, high school, and college baseball are in full swing. Of course, for many players, baseball is no longer limited to a season – it’s played all year round. Before the first pitch of the regular season is thrown out, these athletes have already spent countless hours practicing and conditioning for their sport or playing in off-season leagues. In fact, it’s becoming increasingly common for athletes and baseball players in particular, to play for 10 months out of the year or more. Unfortunately, this increase in play directly correlates with an increase in injuries.

At Beacon Orthopedics and Sports Medicine, we are treating an increasing number of baseball-related elbow injuries each year, including tears in the ulnar collateral ligament (UCL) in particular. In fact, Dr. Timothy Kremchek, whose specialties include arthroscopic treatment and reconstruction of the elbow, routinely treats high school, college, and professional athletes for these “Tommy John injuries.”

The physical demands of baseball as well as the increasing degree of specialization among athletes show no signs of slowing down. While the physical and mental benefits of sports can’t be overstated, neither can the risks of overuse injuries. Here are some easy ways to identify one of the most common injuries in baseball and be ready to discuss treatment with your sports medicine physician.

Ulnar Collateral Ligament Injuries

Anatomy

The elbow is a hinge joint that straightens and bends. It consists of the humerus (the upper arm bone,) the ulna (the larger bone of the forearm,) and the radius (the smaller bone of the forearm.) It also consists of a second joint where the radius meets the humerus. Unlike a simple hinge, this joint rotates, allowing you to twist your wrist (called “supination” and “pronation”) and turn your hand. In order to allow these movements to happen – and often at the same time – the end of the radius is shaped like a socket while the end of the humerus is shaped like a knob. The shape of these two bones allow fluid, gliding motions.

The ulnar collateral ligament (UCL) is a thick triangular band that connects the humerus and the ulna. This ligament, along with the anterior cruciate ligament, holds the elbow joint together and prevents dislocation. In conjunction with several muscles, nerves, and tendons, the UCL stabilizes the elbow during overhand throwing.

A sprain or tear can occur in the UCL either through sudden trauma or gradually develop over time due to the wear or repetitive motions. Nearly all cases requiring Tommy John surgery are due to overuse, not a one-time injury. Once it is torn, the UCL may not heal entirely. Moreover, if the ligament has been overstretched, the elbow may remain loose and unstable.

Signs and Symptoms

In the case of a sudden injury, you may notice a popping sound or tearing sensation at the time of your injury. You may also experience swelling and bruising at the site of the injury.

The symptoms of a UCL injury include:

  • Pain and tenderness on the inner side of the elbow
  • Stiffness and instability within the elbow
  • Numbness or tingling in the hand
  • Difficulty gripping objects
  • Difficulty straightening the wrist

These symptoms are perhaps most noticeable among athletes who are required to throw, such as baseball pitchers and javelin throwers, and those who swing, such as tennis players and golfers. These individuals may find it difficult to throw at full force or experience frequent clumsiness while trying to hold objects.

Causes

UCL tears can be caused by either a sudden, significant force that exceeds the strength of the ligament or through gradual wear caused by repetitive motions.

It should come as no surprise, then, that baseball pitchers are at the highest risk of an UCL injury. As a pitcher’s body goes forward, their arms whip back. This torque, or rotational force, stops the arm from whipping back and gets it to move forward. The ligaments in the elbow, including the UCL in particular, undergo an enormous amount of stress while this happens. In fact, the average pitch places about 50 newton meters of force – or the pressure of holding 2 ½ bowling balls – on your elbow. With athletes expected to throw 100 or more full-force pitches each game, compounded with the widespread problem of improper body mechanics, it’s easy to see how this becomes a big problem for such a tiny ligament.

While UCL damage is most prominent among baseball pitchers, this type of injury can occur within a number of different sports. Athletes who participate in sports that require frequent, repetitive motions – such as tennis or golf – or forceful throwing are at risk. Moreover, sprains and dislocations can result when an athlete lands on an outstretched arm after falling.

Diagnosis

These symptoms vary in severity and are classified accordingly. In a first-degree sprain, the ligament is painful but not lengthened. With a second-degree sprain, the ligament is stretched but still functions. With a third-degree sprain, the ligament has ruptured or otherwise been damaged to the point where it no longer functions.

Only an orthopedic specialist can diagnosis and treat an UCL injury. If you experience pain or difficulty with your elbow, it’s imperative that you meet with a sports medicine physician. You can schedule an appointment with Dr. Kremchek online.

Ulnar Collateral Ligament Reconstruction

Not long ago, substantial UCL damage meant the end of a sports career. It wasn’t until 1974 when orthopedic surgeon Frank Jobe, then a Los Angeles Dodgers team physician, performed an ulnar collateral ligament reconstruction on major league pitcher Tommy John that garnered national attention.

UCL reconstruction, also known as Tommy John surgery, is a procedure in which a damaged ulnar collateral ligament is replaced with either a tendon from elsewhere from the patient’s own body or a donated tendon. The goal of the surgery is to restore medial stability of the elbow, allowing the patient to return to the activities and the level of performance they once had prior to the injury.

Today, the majority of patients who undergo UCL reconstruction have a full recovery. In fact, given the high success rate of the surgery, the term “Tommy John” has become a popular way to reference to UCL tears over the past decade.

Candidates

College and professional level athletes who are required to throw, especially baseball pitchers, are often the candidates most in need of surgery.  Due to a lack of knowledge about overuse injuries, many younger athletes are also requiring surgical care.

Like all forms of surgery, it is a method of last resort. It’s crucial that patients attempt conservative treatment methods first. If their condition does not improve through rest and rehab, the next step is usually to try more aggressive rehab and physical therapy.  It is only after the conservative treatments fail that surgical options are discussed with a sports medicine physician. The decision to proceed with surgery must be made jointly with a physician and only after the surgery is fully understood.

Operation

Over the years, the way that surgeons perform the operation has improved to become less invasive with a decreased rate of complication. With these innovations, there are a number of techniques that an orthopedic surgeon may employ, such as the docking technique or figure eight technique. Despite these variations, however, the procedure follows four basic steps:

  • An incision is made on the inside of the elbow joint
  • A tendon is harvested from another area of the patient’s body (often from the patella) or a donated tendon is prepared
  • The damaged ulnar collateral ligament is removed and replaced
  • The incision is stitched up and the elbow is placed in a large bandage

Arthroscopy is not always necessary but may be done prior to the reconstruction in order to remove any additional problems within the joint.

Aside from being minimally invasive, the procedure is performed on an outpatient basis, allowing the patient to return home the same day.

Recovery

During the immediate days following surgery, the arm will be immobilized by a  bandage and posterior splint with the arm placed in a sling. Patients may also experience slight discomfort at their incision site. Swelling and throbbing can be reduced by keeping the elbow elevated above the level of the heart.

Many patients are able to resume throwing after 16 weeks. It takes about one year for pitchers and six months for position players to achieve a full recovery.

Talk to Dr. Kremchek About Your Options

Dr. Kremchek diagnosing an elbow injury in a baseball playerIn previous generations, athletes played a variety of sports. Naturally, this allowed them to avoid excessive wear on one particular body part. Over recent years, however, many athletes have become specialized not only for a particular sport but for a certain position. Today, you’re more likely to hear an athlete say “I’m a pitcher” or another position than just “I’m a baseball player.”

This high level of specialization, combined with year-round performance, means that athletes are developing microscopic, undetected injuries at an early age. As this trend continues, the risk of elbow injuries within high school and college athletes will become even greater. While “Tommy John surgery” has proven itself to be an effective treatment, preventing the injury altogether is a much better option. Utilizing proper body mechanics and the supervision of an orthopedic specialist will significantly reduce your risk of elbow injury. If you already experience elbow-related problems, however, it’s imperative that you talk with a sports medicine physician.

Dr. Timothy Kremchek is one of the fellowship-trained physicians who provides expertise in elbow repair and reconstruction at Beacon Orthopaedics and Sports Medicine. You can schedule an appointment online to meet with Dr. Kremchek at Beacon’s Summit Woods or Wilmington locations.

With the right care, you can look forward to performing at your absolute best for many years to come.