The mystery behind Tommy John Surgery

Michael G. Ciccotti, M.D. March 19th, 2013

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). 

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.


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