Tommy John Surgery

Ulnar Collateral Ligament (UCL) Injuries

Throwing athletes, more specifically baseball players, of all ages are at risk of injuring their elbow. One of the more common elbow injuries Dr. Ahmad treats is a sprained or torn ulnar collateral ligament (UCL). The reason UCL injuries occur is due to the extremely high stresses on the elbow during the throwing motion. Over time, and without adequate rest and recovery, these high stresses can lead to injury. The UCL is the width of a shoe string and is analogous to a wire hanger. The UCL is compared to a wire hanger because over time, if you bend the wire hanger back and forth enough, the hanger will eventually break—the same is thought to occur in the UCL. If high demands are placed on the UCL, over time, it will fail. Although UCL tears are most commonly seen in pitchers, any athlete who repeatedly throws overhead is susceptible to these types of injuries. When the UCL tears, the most common surgery is called an Ulnar Collateral Ligament Reconstruction. This surgery is more famously known as Tommy John Surgery. Dr. Ahmad honed his skill of UCL Reconstruction Surgery during his Fellowship with Dr. Frank Jobe, who performed the first UCL Reconstruction surgery on Tommy John.

History of UCL Reconstructions
As mentioned, UCL Reconstruction Surgery is famously referred to as Tommy John Surgery. Tommy John was a Major League baseball pitcher that had the first UCL reconstruction. At the time of Tommy John’s surgery in 1974, UCL tears were thought to be career-ending. Not only was the surgery the first of its kind, it also was successful. John returned to the Major Leagues able to continue his career. Today, UCL reconstruction has become a well-known procedure that helps professional, college, and youth athletes continue to compete in sports they enjoy.

Anatomy of the Elbow

Anatomy of the ElbowThe elbow is comprised of three bones: the humerus (upper arm bone), ulna, and radius. The radius and ulna make up the forearm. The elbow serves as a hinge joint as well as a pivot joint. As a hinge joint, the arm is able to flex and extend. As a pivot joint, the forearm has the ability to pronate and supinate (palm up and palm down). Other important landmarks of the elbow include the olecranon, medial epicondyle, sublime tubercle, and cubital tunnel. The olecranon is the bump on the back of the elbow and is part of the ulna. It can be easily seen and palpated. On the inside of the elbow there is a prominent bump called the medial epicondyle. The medial epicondyle is important because it serves as an attachment point for the muscles that flex the wrist as well as the origin of the UCL. The sublime tubercle is a landmark on the ulna where the UCL inserts. The cubital tunnel is the area in which the ulnar nerve is located. Many people know this area as their funny bone. The UCL is one of many ligaments on both the inside and outside of the elbow that help stabilize the joint during movement. Think of the UCL as a rope that connects the medial epicondyle to the sublime tubercle of the ulna. There is a lot of attention from throwing athletes, their coaches, parents, and healthcare team on the UCL since this ligament has to withstand tremendous force during the throwing motion.

Common Throwing Injuries of the Elbow

When athletes throw repeatedly at high speeds, the repetitive stresses can lead to a number of injuries. Problems most often occur at the inside of the elbow because considerable force is concentrated over the inner elbow during throwing. Two common injuries in the throwing athlete include UCL sprains or tears and medial apophysitis.

Ulnar Collateral Ligament (UCL) Injury

The UCL is the most commonly injured elbow ligament in throwers. In throwers, UCL injuries are overuse in nature. Although highly uncommon, these injuries can occur in non-throwing athletes such as gymnasts. Injuries to the UCL can also be traumatic in nature such as dislocations. UCL injuries can include inflammation, sprains, or complete tears of the ligament. Treatment of such injuries vary and multiple factors play a role in determining what the best course of action is for the individual athlete. Athletes with UCL injuries typically complain of pain on the inside of the elbow and many baseball players notice decreased throwing velocity and accuracy.

Little Leaguer’s Elbow (Medial Apophysitis)

Little Leaguer’s Elbow is a common injury on the inside of the elbow in youth athletes between the ages of 13 and 16. This injury is an inflammation in the growth plate of the medial epicondyle. The medial epicondyle is the bump on the inside of the elbow where the UCL originates from as well as serving as an attachment site for the wrist flexor muscles. The reason it is seen in 13 to 16 year olds is because the growth plates in these athletes are not closed yet creating an additional area of stress to be placed on the medial elbow. If not treated correctly, an avulsion fracture of the medial epicondyle may occur requiring surgery for these young athletes.

Cause

Elbow injuries in throwers are usually the result of overuse and increased stress on the structures of the elbow. Generally, the pain will resolve when the athlete is at rest and not throwing. In baseball pitchers, rate of injury is highly related to:

  • the number of pitches thrown
  • the number of innings pitched
  • the number of months spent pitching each year

Research by Dr. Ahmad and other leaders in the field has shown that pitchers who meet the following criteria also have a higher rate of injury:

  • Taller and heavier pitchers
  • Pitchers who throw with higher velocity
  • Pitchers who participate in multiple showcases
  • Pitchers who throw with arm pain or while fatigued

Symptoms

When the UCL becomes injured, the pain can be felt on a specific throw or over the course of an outing. Some athletes will feel a popping sensation in their elbow or tightness in their forearm. Pain may persist even after the outing. In pitchers, symptoms include pain on the inside of the elbow, decreased throwing velocity, decreased accuracy, and the inability to feel loosened up after a warm-up.

Dr. Ahmad’s Elbow Examination

Physical Examination and Patient History

Dr. Ahmad’s elbow examination is comprised of a few different components: a history, observation, palpation, special tests, imaging and assessment. At your initial visit, Dr. Ahmad and his team will ask you pertinent questions about your injury. Once a thorough history is obtained, Dr. Ahmad performs a physical examination that is a combination of observation, palpation, and special testing. During this part of your exam, Dr. Ahmad compares the injured elbow to the healthy side and will check all the structures of your injured elbow while locating important landmarks and checking range of motion. Special testing is a key part of the diagnosis process. The tests Dr. Ahmad performs help our team establish a diagnosis and determine which treatment route will give our patient a most favorable outcome. In addition to a clinical work-up, imaging may be necessary to determine the extent of the injury. Imaging almost always includes an MRI.

Imaging Tests

Tommy John Imaging Tests

MRI Scan of a torn UCL in a pitcher that had Tommy John Surgery with Dr. Ahmad

X-rays: Although X-rays do not show if you have a UCL tear, these images demonstrate clear images of dense structures, like bone. X-rays help diagnose Little Leaguer’s Elbow.

Magnetic resonance imaging (MRI) scan: MRIs are used to determine damage to soft tissues. These scans can help differentiate pain in the medial elbow – whether it is the flexor tendons or the UCL itself. MRIs can also help determine the severity of an injury to the UCL, such as a ligament being sprained or completely torn.

UCL Injury Treatment

Non-surgical Treatment

The severity of the injury dictates the treatment that Dr. Ahmad recommends for the individual patient. For certain conditions, Dr. Ahmad may recommend the following treatments:

Anti-inflammatory Medications: Anti-inflammatories may be over-the-counter or prescription. If an anti-inflammatory is recommended, our team highly suggests undergoing a course of physical therapy as well.

Platelet Rich Plasma (PRP) Injections: PRP injections is recommended only in specific cases. PRP is where blood is drawn from the patient, spun in a centrifuge, and the body’s natural healing agents are extracted and injected to the damaged ligament. After undergoing a series of PRP injections, our team recommends physical therapy to help aid in the healing process.

Physical Therapy: PT is usually done in conjunction with other treatments such as anti-inflammatories or PRP injections. A therapist who works with large number of baseball players is highly recommended. Our office has a list of “Baseball Specific” therapists that we recommend. Generally, there is no throwing in this time period.

Throwing Program: After physical therapy, the arm needs to be reconditioned to throwing. Our office will provide the patient with a detailed program designed to guide the player back onto the field. Dr. Ahmad highly recommends performing all throwing be done in the presence of a pitching coach or someone qualified to identify any poor mechanics in the throwing motion.

Surgical Treatment

If non-surgical treatments fail, or the UCL is torn or severely damaged, surgery may be necessary. Dr. Ahmad performs two types of UCL surgeries.

UCL Reconstruction
Athletes who have torn their UCL typically need a reconstruction. In the Anatomy section, the UCL is referred to as a rope that connects the medial epicondyle and the sublime tubercle of the ulna. If the tear occurs at certain points throughout the ligament, a reconstruction is necessary. UCL Reconstructions are performed openly meaning that an incision is made along the inside of the elbow so the reconstruction can be performed. The ligament is reconstructed with either an autograft or an allograft. An autograft is a tendon that comes from the patient and can either be a palmaris longus tendon or a hamstring tendon. Interestingly, the palmaris longus is absent in 20 percent of the population. Allograft tissue comes from a donor and is treated so it is safe for a recipient to use.

UCL Repair
A UCL repair is an innovative procedure that Dr. Ahmad performs and is an option in unique situations. Referring back to the Anatomy section, recall the UCL is thought of as a rope that connects the medial epicondyle and the sublime tubercle of the ulna. When the UCL is intact but is torn off a landmark, a UCL Repair is possible. In this instance, Dr. Ahmad uses an internal brace that helps suture the ligament back to the bone. The native ligament is used and no other tissues are needed to perform this surgery. Patients that have a repair do just as well post-operatively when compared to a reconstruction surgery.

Surgery Details and Post-Op Care
Both surgical options are performed in an out-patient setting where the patient comes in, has surgery, and goes home in the same day. The time of your procedure will dictate what time you have to arrive at the facility. Surgery itself takes roughly an hour and post-operatively the patient will be in the post-anesthesia care unit (PACU) for 2 to 3 hours depending on how they react to the anesthesia. Anesthesia used is in the form of a nerve block and light sedation, not general anesthesia. The nerve block can last between 8 and 24 hours. The arm is placed in a posterior splint and a sling. The sling is used for the first 24 hours. After 24 hours, the sling is not needed but should be kept for when the patient is in crowded places or in situations where safety is warranted.

After 24 hours, patients are able to remove the sling and shower. The splint must stay on for 5 days so a plastic bag is recommended to cover the dressing. Patients should return to the office 5 days post-operatively to have the splint removed. At this visit, the sutures are removed and a brace is applied to the elbow. Physical therapy starts within 5 days of having surgery. The brace is worn throughout the day and night for 4 to 6 weeks after surgery. There are a few medications that are prescribed for any post-operative discomfort and our team will go into details in the office should you be a candidate for surgery. Our team will explain all details of surgery in the office as well as post-operative care at length and answer all questions that may come up!

Treatment for Little Leaguer’s Elbow

Treatment for Little Leaguer’s Elbow is symptom-related. After imaging is reviewed, Dr. Ahmad may recommend the following treatment:

Rest: Dr. Ahmad may recommend a period of complete rest for a specific time frame. During this period, no throwing or strenuous exercise is allowed. Anti-inflammatories may be recommended during this time frame as well.

Anti-inflammatory Medications: Anti-inflammatories may be over-the-counter or prescription. If an anti-inflammatory is recommended, our team highly suggests undergoing a course of physical therapy as well.

Physical Therapy:  PT is usually done in conjunction with other treatments such as anti-inflammatories or PRP injections. A therapist who works with large number of baseball players is highly recommended. Our office has a list of “Baseball Specific” therapists that we recommend. Generally, there is no throwing in this time period.

Throwing Program: After physical therapy, the arm needs to be reconditioned to throwing. Our office will provide the patient with a detailed program designed to guide the player back onto the field. Dr. Ahmad highly recommends performing all throwing be done in the presence of a pitching coach or someone qualified to identify any poor mechanics in the throwing motion.

Recovery and Return to Sports

PRP Treatment: In most cases, three PRP injections are recommended. After the second injection, physical therapy is initiated. Around six weeks after the first injection a re-evaluation is performed to see if the player is ready to begin a throwing program. Before an athlete returns to competition is about 3 months.

UCL Reconstruction/Repair: For surgical procedures, physical therapy is initiated around 5 days post-operatively. It is typically 4 ½ months before the athlete begins throwing a baseball again. This first throwing program is performed on the flat ground and is 4 ½ months in duration. At the 6 month mark from surgery, hitters are given a specific program and are allowed to swing a bat again. At the completion of the flat ground throwing program a position-specific program is undertaken which varies depending on the athlete. Pitchers will get on the mound at this point while position players are given a protocol specific to their position. Return to full competition can range from 8-14 months.

Little Leaguer’s Elbow: Treatment may occur for an unspecified period of time. A player may be allowed to begin a throwing program once their physical exam is considered normal and based on the player’s pain. Further imaging may be required throughout the treatment period.

*Note: All timelines are meant as a guide and each player’s actual timeline may vary*

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Tommy John Surgery-Related News

Dr. Ahmad Moderates Round Table Discussion on Elbow UCL Injuries

January 31, 2017

“The goal of the discussion is to elicit expert opinion about the reasons for increased numbers of UCL injuries, elucidate the scope of the problem, understand prevention strategies, establish realistic expectations for nonoperative and operative treatment, and provide thoughts about the future.”

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