Tommy John Surgery

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Overview

The Ulnar Collateral Ligament (UCL) is the most commonly injured elbow ligament in throwers. 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, and can include inflammation, sprains, or complete tears of the ligament. Treatment of such injuries vary with multiple factors playing a role in determining what the best course of action is recovery. Athletes with UCL injuries typically complain of pain on the inside of the elbow and many baseball players notice decreased throwing velocity and accuracy. As a result they are more likely to need to have their elbow's UCL repaired or reconstructed with Tommy John surgery at some point in their playing career.

UCL injuries are generally caused by:

  • Overuse
  • Increased stress on the structure of the elbow
  • For pitchers specifically, the following factors can contribute to the likelihood of injury:
    • the number of pitches thrown
    • the number of innings pitched
    • the number of months spent pitching each year
    • throwing with existing arm pain
    • throwing with high velocity

Your UCL is: One of many ligaments on both the inside and outside of the elbow that help stabilize the joint during movement.

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—it also serves as an attachment site for the wrist flexor muscles. The reason it is seen in age range is because the growth plates in these athletes are not yet closed—this creates 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.

Anatomy of the Elbow


The 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: The bump on the back of the elbow and is part of the ulna. It can be easily seen and palpated.
  • The Medial epicondyle: Serves as an attachment point for the muscles that flex the wrist as well as the origin of the UCL.
  • The Sublime tubercle: A landmark on the ulna where the UCL inserts.
  • The Cubital tunnel: The area in which the ulnar nerve is located.

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.

The Facts on Tommy John Surgery:

  • At the time of Tommy John’s surgery in 1974, UCL tears were thought to be career-ending.
  • Elbow injuries in throwers are usually the result of overuse and increased stress on the structures of the elbow.
  • In baseball pitchers, rate of injury is highly related to the number of pitches thrown, the number of innings pitched, and the number of months spent pitching each year.

History of UCL Reconstructions

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 surgery in 1974. At the time of Tommy John’s surgery, UCL tears were a career-ending injury.
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 love.

Symptoms

The following symptoms are commonly reported by patients with an injured UCL:

  • A “pop” sound at the time of injury
  • Pain
  • Stiffness
  • The inability to feel loosened up after a warm-up
  • For pitchers specifically, pain inside of the elbow, decreased velocity and accuracy

Evaluation by Team Ahmad

Dr. Ahmad and his team of health professionals will greet you and start your visit with a discussion of your symptoms, sport, level of competition, or desired activity level. Next, the doctor will exam your elbow, focusing on:

  • Palpation surrounding the elbow
  • Your elbow's range of motion
  • Tenderness surrounding your elbow

Imaging Tests

Dr. Ahmad may order imaging tests to help confirm the diagnosis.

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 display dense structures, like bone. X-rays help diagnose Little Leaguer’s Elbow.
 
Magnetic resonance imaging (MRI): 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.

Treatment Options

Dr. Ahmad will recommend treatment based on:

  • The severity of your UCL injury
  • Your activity level
  • Timing during your sport's season
  • The type of tear you have and its size
  • Location of pain, swelling, and tenderness

Non-Surgical

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. Physical therapy is recommended after an injection.
  • Physical Therapy: Physical therapy 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.
  • Throwing Program: 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

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
    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 (a tendon that comes from the patient) or an allograft(tissue received from a donor).
  • UCL Repair
    A UCL repair is an innovative procedure that Dr. Ahmad performs and is an option in unique situations. When the UCL is intact but is torn off a landmark, a UCL Repair is possible. Dr. Ahmad uses an internal brace that helps suture the ligament back to the bone. Patients that have a repair do just as well post-operatively when compared to a reconstruction surgery.

Rehabilitation and Recovery

Both surgical options are performed in an out-patient setting where the you'll come in, have your surgery, and go home in the same day. Surgery itself takes roughly an hour and post-operation will be in the post-anesthesia care unit (PACU) for 2 to 3 hours depending on how you react to the anesthesia.

1st 24 hours

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 that, the sling is not needed but should be kept for when you are in crowded places or in situations where additional caution is warranted.

Second Day

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-surgery to have the splint removed. At this visit, the sutures are removed and a brace is applied to the elbow.

Longer-Term Recovery and Returning to Sports

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.

PRP Treatment: In most cases, three PRP injections are recommended. After the second, 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. The athlete should anticipate returning to competition in approximately 3 months.

UCL Reconstruction/Repair: For surgical procedures, physical therapy is initiated around 5 days after the operation. 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. Return to full competition can range from 8-14 months.

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

Dr Ahmad's Experience

Resources

Baseball Health Network
MLB Pitchsmart

Tommy John Surgery-Related News

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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