Tommy John Surgery

Tommy John surgery is a commonly used name for ulnar collateral ligament (UCL) reconstruction. There are several different methods to reconstruct torn UCL, such as Jobe procedure, docking technique, modified docking technique, DANE procedure, etc. There are different fixation methods, different graft donating sites, different approach to the ligament, etc. Originally, the procedure was done detaching the forearm muscle group to access the reconstruction site. However, it is more common now to split the muscle instead of detaching it. Usually, the muscle in the forearm called palmaris longus is used as a graft, however, it can be taken from the knee muscle. Also, originally, ulnar nerve transposition (relocating the 'funny bone' nerve) was done at the same time the Tommy John surgery was done. However, it may not be done unless the athlete is having ulnar nerve symptoms. There are several variations to this procedure, but, the goal of the surgery is to regain stability to the elbow by reconstructing a torn UCL which provides static constraint to the medial side of the elbow in throwing motion. 

       Rehabilitation after UCLR is a long process. It usually takes about 10-12 months to return to full pitching activities. Even after returning to full pitching, a pitch count and innings pitched may be limited. Studies show about 85% success rate after the procedure. However, it may take longer than 12 months to return to pre-injury performance level. Recently, Stephen Strasburg of Washington Nationals came back from Tommy John surgery and seems to be pitching well. Joe Nathan (Texas Rangers) is in his 2nd year coming back, I believe. Fransisco Lariano (Minnesota Twins) seems to be struggling. Adan Wainright (St.Louis Cardinals) is pitching his first season after the surgery.

       We will discuss rehabilitation after UCLR later.     

UCL Injury in Baseball Pitchers

It's only a few weeks into Major League Baseball season and there have already been a few pitchers  that are out of UCL tear requiring surgery. But what is UCL? Why is this so common? The ulnar collateral ligament of the elbow (UCL) is located in the medial side (inside) of the elbow connecting two bones (humerus and ulna) and plays a primary role in stabilizing the joint during pitching motion, especially during cocking phase. It is also under considerable amount of stress close to its maximal capacity before it fails according to the literature. The muscles around the ligament and joint also play a role as a dynamic constraint to protect the joint and the ligament from an injury. However, over time and from repetitive stress from pitching may put enough stress to injure the ligament. A tear can happen in one pitching motion, however, the most of the times, it is from overuse. Can we prevent this?! Sure, we can! It is important that pitchers especially in younger age limit their pitch count. One study shows that younger pitchers who pitch more than 100 innings per year are 3.5 times more likely to injure their shoulder or elbow. It is also important that they learn a good pitching mechanics. We know that poor throwing mechanics will put more stress in the shoulder and the elbow. We also need to address the whole body as kinetic chain because the majority of the strength to throw baseball is created in the lower extremities not in the throwing arm. Any break in the kinetic chain will result in more stress placed on some other parts of it. Imagine throwing baseball on the firm ground, then, in the mud.....it would be more difficult to throw hard in the mud, right?! That's how important the legs are in order to be able to throw or pitch.

Ulnar Colleteral Ligament of the Elbow

   

Core Stabilization Exercise III

In our past post, we discussed basic core strengthening exercises such as pelvic tilt or draw-in exercise. This is the fundamental of core exercises because that position has to be maintained during any core exercises. Click here to read the post. There are numerous things you can do to make it harder once draw-in exercise can be achieved easily. One way to do it is to add arm and leg movements. From that draw-in position, you can slide one led down straightening the leg and  slide it back up and alternate legs. Once again, the draw-in position must be maintained during leg movement. Dead-bug exercise is more advanced core exercise. Plank is also a good core stability and endurance exercise. It can also be made more difficult by using an unstable surface (see picture).  Burdock, lower trunk rotation, multifidus walk, etc. also are a good core exercises. However, theses exercises only mean a little if the fundamental of core exercise is not established.

What We Don't Know about ACLR: Grafts' Health

Athletes can return to sports successfully after ACLR even though there are chances of re-injury. Rehabilitation process has been shortened and they may return as soon as 4 months post-operatively. However, it is unclear that what is healthy and what is unhealthy to do in a rehabilitation process. We do know what puts stress on the graft and mechanisms of injury. So, we need to avoid things that stress it. For example, during the last 30 degrees of open kinetic knee extension, ACL is under stress from quadriceps muscle contraction force. But we can only assume that things such as walking, weight-bearing, not using a knee brace or crutches are safe to do. But we do not know for sure that it is safe in a long run. We just know that athletes do well either way and it does not appear to affect rehabilitation process or re-injury rate. It is difficult to know how safe and what is safe without knowing graft maturation process and when they are ready to do what. To our knowledge, there are no studies that show when it is too early to do what in terms of graft safety and re-injury rate. We just know the most athletes do well with current ACLR rehabilitation protocols. We feel like there are a lot more studies to be done on this topic especially some studies suggest that ACL grafts elongate after surgery as much as 3mm compared to graft length at the time of reconstruction. Some studies show that re-injury rate after ACLR in active people may be up to 18%. There are many things we know about ACL compared to 10 years ago, but, at the same time, there are many things we do not know yet.