Wednesday, November 25, 2015

The mystery behind Tommy John Surgery

Baseball players expose their elbows to a tremendous variety of forces during the full act of throwing. Normally there is an amazing balance between the muscles, tendons, ligaments and bones that allow these athletes to perform painlessly. But sometimes that balance is lost, and injury may occur.

The mystery behind Tommy John Surgery


Editor's note: This is the first installment in a series by Dr. Michael Ciccotti, MD, Head Team Physician for the Phillies. Dr. Ciccotti is the leader of a group of MLB team physicians currently studying throwing injuries. This series will attempt to answer questions about the infamous—yet mysterious—ulnar collateral ligament, the portion of the elbow that is repaired in ‘Tommy John Surgery.’

Baseball players expose their elbows to a tremendous variety of forces during the full act of throwing. Normally there is an amazing balance between the muscles, tendons, ligaments and bones that allow these athletes to perform painlessly. But sometimes that balance is lost, and injury may occur.

Perhaps one of the most devastating elbow injuries involves the ulnar collateral ligament (UCL)—the same injury that has sidelined numerous professional players such as, most recently, Stephen Strasburg of the Washington Nationals.

But what is it that is so vital about the UCL? Numerous studies have shown that the UCL is the primary stabilizer of the elbow during the act of throwing. When injury such as partial or complete tearing occurs, baseball players, particularly pitchers, are often unable to throw competitively. This ligament may be injured with one throw (acute injury) or progressively over a period of time (chronic injury). 

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How does injury to the UCL present in the thrower? Several common symptoms occur with this injury:

  1. Pain along the medial or inner aspect of the elbow while throwing
  2. Sudden pop or snap along the inner elbow
  3. Numbness or tingling into the hand and fingers (ring & little)
  4. Noticeably decreased throwing velocity
  5. Diminished throwing control 

Evaluation by a Sports Medicine Specialist is important in diagnosing this injury. Several common signs are present on examination: tenderness along the inner aspect of the elbow, pain with stress applied to the UCL and decreased sensation in the ring & little fingers. Some throwers may also experience weakness in the hand muscles.

The physician often performs plain X-rays to show any bony fractures or chips, followed by a MRI to see if there is a partial or complete UCL tear. Finally, a dynamic ultrasound is performed to determine if the UCL injury has resulted in laxity.

If the symptoms, examination and imaging studies indicate a tear of the UCL, then the physician will initiate treatment. For mild or partial tears without significant elbow laxity, a nonoperative program is begun. This may include:

  1. Rest from throwing for 3-6 weeks
  2. Anti-inflammatory medication if the athlete’s medical history allows it
  3. A comprehensive rehabilitation program for the athlete’s elbow, shoulder, core(abdomen), hips and legs under the guidance of a physical therapist or trainer
  4. A progressive tossing/throwing program after the 3-6 weeks of rest

An athlete with a complete tear or with a partial tear that does not respond to nonoperative treatment may require surgery… otherwise known as “Tommy John” Surgery. Stay tuned for the next part of this blog series, which will discuss the fact and fiction of this famous surgery.

Head Team Physician for Phillies & St. Joe's; Rothman Institute
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Sarah Whitman, MD Sports Psychiatrist in Philadelphia
Tracey Romero Sports Medicine Editor,
J. Ryan Bair, PT, DPT, SCS Founder and Owner of FLASH Sports Physical Therapy, Board Certified in Sports Physical Therapy
Brian Cammarota, ATC, PT, DPT, CSCS Partner at Symetrix Sports Performance
Ellen Casey, MD Physician with Drexel University Sports Medicine
Desirea D. Caucci, PT, DPT, OCS Co-owner of Conshohocken Physical Therapy, Board Certified Orthopedic Clinical Specialist
Michael G. Ciccotti, M.D. Head Team Physician for Phillies & St. Joe's; Rothman Institute
Julie Coté, PT, MPT, OCS, COMT Magee Rehabilitation Hospital
Peter F. DeLuca, M.D. Head Team Physician for Eagles, Head Orthopedic Surgeon for Flyers; Rothman Institute
Joel H. Fish, Ph.D. Director of The Center For Sport Psychology; Sports Psychology Consultant for 76ers & Flyers
R. Robert Franks, D.O. Team Physician for USA Wrestling, Consultant for Phillies; Rothman Institute
Ashley B. Greenblatt, ACE-CPT Certified Personal Trainer, The Sporting Club at The Bellevue
Eugene Hong, MD, CAQSM, FAAFP Team Physician for Drexel, Philadelphia Univ., Saint Joe’s, & U.S. Lacrosse
Brian Maher, BS, CSCS Owner, Philly Personal Training
Julia Mayberry, M.D. Attending Hand & Upper Extremity Surgeon, Main Line Hand Surgery P.C.
Gavin McKay, NASM-CPT Founder/Franchisor, Unite Fitness
Heather Moore, PT, DPT, CKTP Owner of Total Performance Physical Therapy, North Wales and Hatfield, PA
Justin Shaginaw, MPT, ATC Athletic Trainer for US Soccer Federation; Aria 3B Orthopaedic Institute
Thomas Trojian MD, CAQSM, FACSM Chief of the Division of Sports Medicine at Drexel University
Justin D'Ancona
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