With the news that Washington Nationals (and former Syracuse Chiefs) phenom pitcher Stephen Strasburg had a torn ulnar collateral ligament (UCL) of the elbow, the sports world was once again reminded how important this ligament is to throwers and how devastating an injury this is to throwers. The surgery to reconstruct the torn ligament in his elbow has been performed and the long year-to-year-and-a-half rehab begins. The surgery that he had was called “Tommy John” surgery.
What is Tommy John surgery? This surgery involves reconstructing the anterior band of the UCL. Ligaments connect bone to bone and provide stability to joints. The ulnar collateral ligament UCL is on the medial (inside) portion of the elbow and protects the elbow against valgus (forces away from the body) during the throwing motion. The ulnar collateral ligament connects the humerus bone, the upper arm bone, to the ulna, which is the medial one of the two forearm bones.
Research performed by the American Sports Medical Institute in Birmingham, Ala. has shown that the UCL is strong but interestingly, the force that it takes experimentally to rupture the ulnar collateral ligament is just slightly more than the amount of force generated while throwing a baseball pitch. In other words, with every throw, the force generated by that throw is almost enough to rupture that ligament in and of itself. If that is the case, why doesn’t the ligament rupture after every throw or more often? Part of the reason is that the muscles and bones/bony structures themselves around the joint help absorb some of that force that is generated while throwing.
Having said that, as a pitcher continues to throw during a game, he becomes more and more fatigued, the muscles get weaker and weaker and they are able to absorb less and less force, resulting in more and more force being transferred to the ligament with each pitch, placing it at increased risk. In addition, repetitive throwing and/or overuse can lead to chronic muscle fatigue, which can lead to repetitive microtrauma (small amounts of tearing over time that add up) in the ligament that the body is unable to heal adequately due to the repetitive stresses of throwing.
Factors shown to increase this risk of repetitive microtrauma are throwing too many pitches in a game, throwing too many innings in a year and throwing different types of pitches that put more stress on the elbow such as curveball, slider, etc. versus a fastball and/or change-up, which put less stress on the elbow.
The repetitive stress of throwing can lead to either a chronic (slow build-up) tearing of the ligament versus an acute (on one pitch for example) episode of tearing. Once the ligament tears, it usually does not heal back normally or does not heal well enough to support repetitive high-stress throwing again.
This usually leads to surgery if a conservative course of three to four months of rehabilitation does not work. The surgery itself is fairly “ingenious.” The reason it is called Tommy John surgery is that there was a pitcher in the 1970s by the name of Tommy John. He pitched for the Los Angeles Dodgers and he tore his UCL. Dr. Frank Jobe, in Los Angeles, invented an operation where he took a tendon from the forearm and transplanted it across the two bones, i.e. the humerus and ulna, along the medial side of the elbow, recreating a new ligament. He drilled two holes and made a tunnel in the ulna bone of the forearm and drilled tunnels in the humerus as well, looping the tendon in a figure eight fashion around the two bones, sewing the ends of the transplanted tendon together and creating a new ligament.
The UCL actually contains three bands: the anterior band, which is the strongest, the posterior (back band) and the transverse band, which does not provide much, if any, structural support. The anterior band is the band that is the most important and is the one that has been found to be the main stabilizer to the valgus (arm going away from the body) stress of throwing. In other words, with each pitch, the high valgus stress forces from the throw try to separate the humerus and ulna from each other, but the UCL holds the two bones together with the help of the muscles. The surgery reconstructs the anterior band of the ulnar collateral ligament using either a forearm tendon, hamstring tendon, foot tendon or cadaver tendon graft. The surgery is usually performed within one to three hours, depending on the complexity of the case and the experience of the surgeon. The recovery is a much longer period. Range of motion of the elbow begins immediately. Strengthening slowly begins. Swelling reduction begins and it takes six to eight weeks for the tendon to become vascularized and start to become a new ligament.
The strength continues to go up until about four months, when the patient is allowed to first start to lightly throw. There is an Interval Throwing Program that gradually increases over the next several months to the point where eventually, at nine months on average, the patient is able to start throwing off the mound. Once they throw off the mound, it is usually about three more months until they are able to get back in a game, i.e. a year to sometimes even one and a half years. Many times patients do improve from where they were pre-injury but the reality of the situation is that a third improve, a third stay the same and a third don’t improve.
The good news is this surgery is usually very effective, however it is not foolproof. About 80 to 85 percent of patients in the best hands are able to get back to the level, or higher, they were at before, which means that 15 to 20 percent do not. So the athlete needs to know that the surgery is not 100-percent effective and not everyone makes it back from Tommy John surgery. From the time Tommy John had his original surgery to the present, the surgery has become much more successful and effective.
Unfortunately, it is also becoming more common. Dr. James Andrews, who is now the leading sports medicine physician in the world, and the leading Tommy John surgery surgeon in the world, has even stated that he feels that UCL injuries are becoming more and more common in younger and younger patients, i.e. it is becoming an epidemic in youth sports.
There are several preventative programs that can be utilized, the most important of which is limiting the amount of pitches per game, innings and pitches per year. For more information on stopping youth sports injuries, go to www.STOPSportsInjuries.org.
Dr. Pietropaoli is a leading fellowship-trained orthopedic sports medicine surgeon and is the CEO, president and founder of Victory Sports Medicine & Orthopedics, 791 W. Genesee St., in Skaneateles. He trained under the world-renowned orthopedic sports medicine surgeon Dr. James Andrews in Birmingham, Ala. and learned how to perform “Tommy John” surgery by Dr. Andrews during his one-year fellowship. Pietropaoli can be contacted at 685-7544.