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.   

Soft Tissue/Bony Adaptation in Throwing Elbow

It is known that our body has an ability to adapt in response to stress placed on it. Muscles get bigger and stronger after weight lifting. Endurance improves after prolonged exercise. In similar way, properties of joints and soft tissues changes as a result of stress placed on them. For example, in overhead athletes, they will lose the amount of internal rotation range of motion (ROM) and gain external rotation ROM, commonly known as GIRD (glenohumeral internal rotation deficits). In throwing elbow, as a result of repetitive throwing motion, soft tissue and bony adaptation about the elbow joint occurs. During throwing motion, distractive force is placed on the medial side (inside) of the elbow, where ulnar collateral ligament is. Compressive force exists on the lateral side (outside) of the joint. Also, stress is placed between trochlea and olecranon on the back of the elbow joint. After repetitive stress placed on the joint, it is shown that properties of UCL may change without any symptoms. In a study conducted on non-injured high school-aged baseball pitchers, MRI's were taken on their throwing elbows and non-throwing elbows and those images were compared. They found out that more than 60% of pitchers had thickening of the ligament in throwing elbow. Also, they found sclerosis in ulnar-throchlea joint without symptoms. Sclerosis means hardening of a bone mainly as a result of repetitive direct contact between two bones. We do not know it this will be a risk factor for future injuries or this may indicate anything significant. However, even in healthy pitchers, these changes do occur. When evaluating throwing athletes, it is important to know that these changes in MRI may not indicate an actual injuries if it is not consistent with objective and subjective evaluation. Other findings in the study was edema around UCL attachment, bone spur, etc. Further studies will be needed to investigate whether this soft tissue and bony adaptation may indicate risks of future injuries.  

MRI image of UCL tear

What We Don't Know about ACLR: Graft Maturation

       We have talked about rehabilitation after ACL surgery. However, there are many things that are not clear to us. What we know is based on clinical trials and studies done in the past and their results are consistent. When it comes to how ACL grafts go through maturation process, it is not that clear. Once ACL graft is in place, it goes through a process of vascularization and maturation. We do not know at what point the graft is strong and mature enough to do what. All we know is that we have been successful rehabilitating those patients following protocols (to note, there are a bunch of different protocols). And time to return to sport has shortened. But we do not know whether it is safe and healthy to a graft.

       A study took a look at when ACL grafts finish their vascularization process based on MRI. It showed that it might take up to a year for the grafts to vascularize. Once again, we do not know if it is safe to return the athletes to sport before the vascularization process is finished. One thing to note is that studies done in Indianapolis using accelerated rehabilitation protocol showed that up to 20% of athletes younger than 18 years of age re-injured or tore ALC after returning to sport.

      There have been so many studies done on ACL tears and rehabilitation. However, this stays as a hot topic in sports medicine. One reason probably is that there are so many things we do not know yet.  

Rehabilitation after ACL Tear: 16 Week Post-Op and Return to Play

By week 16, agility and plyometric exercise can be initiated if the injured athlete has good proprioception, postural stability, and strength. However, those exercises should not cause any pain or other complications like swelling. Balance and proprioception are hard to measure objectively. Some may use how long they can balance on one leg and other may use BEST as a measurement. Strength may be hard to measure also if isokinetic machine or hand-held dynamometer are not available. However, before plyometric training is initiated, the athlete should have about 80% of the strength back when compared to the uninjured side.

Then, the athlete can gradually progress to sport-specific training and back to practice. The return to play criteria should include 1) full ROM, 2) no pain, 3) no swelling, 4) optimal strength (at least 85% compared to the uninjured side), especially quads, 5) good proprioception and postural stability, 6) good mechanics (risky movements such as jump-landing, cutting motion, etc.), 7) no instability. It is also important to ready the athlete psychologically.

Rehab program should also include injury prevention program for both of the knees since some studies show that athletes with history of ACL injury may be more at risk of reinjurying the same knee or the other knee. It usually takes about 6 months plus minus one month until return to sport.   

2 leg box jump (start)

finish