A roundtable on “Tommy John” injuries
The first ulnar collateral ligament (UCL) injury in a professional athlete was identified in a javelin thrower and reported in the literature in 1946. Today, these injuries are common among overhead-throwing athletes, especially baseball pitchers.
In 1974, Frank J. Jobe, MD, performed the first reconstructive surgery for the UCL on pitcher Tommy John, for whom the surgery was later named. Recently, AAOS Now editorial board member Frank B. Kelly, MD, discussed this injury with the following leaders in the field:
- James R. Andrews, MD, a founding member of Andrews Sports Medicine and Orthopaedic Center in Birmingham, Ala., a member of the Medical and Safety Advisory Committee of USA Baseball and the Board of Little League Baseball, Inc., and medical director of the Tampa Bay Rays
- James P. Bradley, MD, clinical professor of orthopedic surgery at the University of Pittsburgh School of Medicine, team physician for the Pittsburgh Steelers, and consultant for the Miami Marlins
- Thomas John Noonan, MD, of the Steadman Hawkins Clinic in Denver, Colo., and head team physician for the Colorado Rockies.
- Neal S. ElAttrache, MD, of the Kerlan-Jobe Orthopaedic Clinic, Los Angeles, and team physician for the Los Angeles Dodgers
- Kevin E. Wilk, PT, DPT, associate clinical director for Champion Sports Medicine (a physiotherapy facility) in Birmingham, Ala., and the rehabilitation consultant for the Tampa Bay Rays
The discussion started with the pathology, mechanism of injury, precipitating factors, diagnosis, and nonsurgical management of these injuries. Part two of this roundtable will focus on surgical management and rehabilitation.
Dr. Kelly: The incidence of UCL injuries has greatly accelerated; it’s been estimated that one in three professional baseball pitchers have had a UCL reconstruction. Dr. Noonan, could you give us a description of the pathology and typical mechanism of injury?
Dr. Noonan: Although many UCL injuries are acute, they typically are acute-on-chronic, meaning a degenerative UCL sustains an acute injury and becomes clinically significant.
With regard to mechanism, these injuries result from repetitive overhead throwing. The valgus stress imparted to the elbow creates microtrauma in the ligament, leading to fiber degeneration and, sometimes, calcification. Over time, this can lead to ligament insufficiency with resultant pain and laxity.
Dr. Kelly: Dr. Wilk, could you address the impact of a longer playing season—8 to 10 months a year—and other precipitating factors on younger baseball players?
Dr. Wilk: In youth baseball players, it appears that playing too much, playing when fatigued, and other factors come into play. In these young players, UCL injuries are due to overutilization—not only playing year-round baseball, but pitching too much in a given game or a given week—and not getting enough rest. That’s why pitch counts have been established, depending on the age of the player. But some youth baseball players play in multiple leagues or play pick-up ball on the side so even though they’re not pitching on their primary team, they are continuing to pitch.
The other problem is fatigue. A pitcher who is fatigued has a 36 times greater risk of sustaining an elbow or shoulder injury that may lead to surgery.
Dr. Andrews: Fatigue is the number one factor, regardless of age or level of activity. We’re also finding that about 60 percent of professional players had a precipitating minor injury to the UCL when they were in youth baseball. As they move through high school, college, or a minor league professional level, the injury progresses. Then, as relatively young major league professionals, they have a catastrophic injury and find themselves needing a surgical procedure.
Several years ago, we studied youth baseball players, 18 years and younger, who required Tommy John surgery. We studied their risk factors and found that they averaged one week off each calendar year when they were not throwing at a high level. So year-round baseball is a problem.
Specialization—playing one sport year-round—is also problematic. Many highly skilled major league pitchers of the past played four sports in high school and didn’t specialize in baseball until they were seniors. But specialization is occurring now at youth levels in all sports, leading to overuse. In addition, these kids are training as though they are professional athletes. They’ve got a pitching coach two nights a week. They’re on a high school team during the week, in a travel league on the weekends, and participating in showcases during the fall, so they can get college scholarships with the hope of becoming major leaguers.
Injury rates have increased anywhere from seven- to tenfold in the last 10 years. In 2000, I think I performed only nine Tommy John surgeries on high school or younger baseball players. Now, the high school and younger group is the largest patient segment. That is why the American Orthopaedic Society of Sports Medicine’s Sports Trauma and Overuse Prevention (STOP) program is trying to educate parents, family, coaches, and the general public about preventing youth sport injuries.
Dr. Kelly: Dr. Bradley, could you address how the diagnosis is made—maybe the history and physical examination?
Dr. Bradley: The history usually reveals two types of incidents. The first is an acute pop and the player can no longer throw or accelerate over 75 percent. Velocity decreases significantly and control decreases. The second group has vague pain, takes longer to warm up, and has problems with motion, control, and velocity. An examination will find an injured UCL.
It usually occurs in late cocking or early acceleration. The physical findings are typically pain over the UCL. However, the entire upper extremity should be checked because many younger players already have shoulder issues, such as glenohumeral internal rotation deficit (GIRD) or some other kinetic chain deficit.
We use a valgus stress test to unlock the elbow at about 30 degrees and look for a relative increase in laxity of about 2 mm from one side to the other. A milking maneuver can be used to assess the posterior band of the anterior bundle. I also like to use the moving valgus stress test, moving the elbow through a range of motion to find the sheer angle—usually between 70 and 120 degrees—that is the patient’s maximal pain angle.
Pitching more than 8 months a year increases the risk of needing surgery by 500 percent, compared to the normal population. Throwing more than 80 pitches a game increases the risk by 400 percent and throwing a fast ball faster than 85 miles an hour increases the risk by 250 percent.
Dr. Kelly: I know that some of these players don’t have a lot of laxity on the valgus stress test. Are you comfortable with the physical exam?
Dr. Bradley: I learned from Dr. Jobe himself. When I asked him how he knew, he said “sensitive fingers and thousands of exams.” I basically agree with him.
If I do a good history and physical, I am fairly sure of my diagnosis most of the time. An MRI of the elbow isn’t necessary; the way I look at it, the history and physical examination are key to the surgical decision.
Dr. Kelly: An MRI can show almost anything on the scan. What do you look for when you get imaging studies for a collateral ligament injury?
Dr. ElAttrache: In the typical scenario, normal ligaments don’t generally rupture. Tissue that ruptures has a failed healing response from years of microtrauma and is weak.
Usually, imaging reveals a thickening of the tissue, a heterogeneous signal that indicates interstitial scarring, and interstitial failure within the tissue itself. I look for confounding things that may affect the surgery or recovery.
Sometimes, overgrowth of bone—both on the sublime tubercle and the olecranon itself—can be seen, as well as edema in the bony structures where the ligament attaches. One of the differential diagnoses of UCL tearing is stress reaction and stress fractures of the olecranon.
Usually the history and physical examination will narrow the diagnosis to the ligament and/or bony reaction to the ligament failure.
The quality of the tendon will affect the prognosis and whether the elbow will heal with or without surgery. Any significant degree of interstitial tearing or tendinosis of the flexor pronator tendon will affect the healing prognosis. If that tendon has an undetected tear, it may affect rehabilitation, leaving the elbow still painful.
Dr. Kelly: That’s a good point. Do you typically get a regular MRI or an MRI arthrogram?
Dr. ElAttrache: I like regular MRIs without contrast because I can see edema in a patient with a new injury. If the patient had a reconstruction, or if a diagnostic dilemma exists, an MRI arthrogram may show a small partial thickness peel off the ulna. But I usually save the dye injections to check the integrity of a previous graft.
Dr. Kelly: Dr. Wilk, as a clinical physical therapist, what do you think about nonsurgical management of these patients?
Dr. Wilk: Nonsurgical treatment is often very difficult and unsuccessful. Obviously, it depends on a lot of factors, including concomitant injuries, severity of the UCL damage, how long the patient has been pitching, the mechanics, and so forth. According to a study reported in 2001, of 31 overhead athletes treated nonsurgically, only 42 percent were able to return to play. The average time to return to play was 24 weeks.
A more recent study involved 34 overhead athletes with confirmed partial thickness UCL tears on MRIs treated with platelet-rich plasma (PRP) and a conservative, well thought out rehabilitation program. In this group, 88 percent returned to the same level of play without complications at an average of 12 weeks. However, these throwers were held to no throwing at all for almost 3 months before they began a throwing program.
If a high grade UCL injury is suspected, it would probably be best to delay throwing as long as possible because most, if not all, of the stress on the UCL is due to excessive external rotation. Exercises for the biceps, triceps, wrist, and rotator cuff place little stress on the UCL as long as there aren’t extremes of external rotation. With elbow flexion/extension, the strain on the UCL is next to zero.
Conventional rehabilitation is recommended to rest the ligament, improve neuromuscular control and flexor pronator strength, and normalize motion, building in some plyometrics or towel throwing at 8 to 10 weeks. When the physician deems appropriate, a throwing program may begin.
Dr. Kelly: Do you have any luck in evaluating pitcher mechanics and making modifications to the way they throw the ball?
Dr. Wilk: It depends on the age of the participant. In younger kids, yes; in college-age or professional players, minimal.
If young throwers have shoulder weakness, they lead with their elbows. If they don’t have proper range of motion, they’ll develop a compensatory mechanism that can lead to injury. Factors such as an injury, surgery, or even pitching when fatigued can alter the player’s normal throwing mechanics and may ultimately lead to an injury to the throwing arm.
Dr. Noonan: We looked at the impact of nonsurgical treatment on UCL injuries in the Colorado Rockies organization. Although full-thickness tears self-selected into the surgery group, 45 players with partial injuries were treated nonsurgically and had a 90 percent return-to-play rate. These results would suggest that a fair number of players actually may do fine with nonsurgical treatment.
However, this involved a very conservative treatment protocol, with up to 6 weeks of no throwing at all. Before I let people throw, I will do a Moving Valgus Stress Test in clinic and see if they are asymptomatic. That is the key factor in deciding when to let the athlete begin a throwing program.
Dr. Andrews: I’m frequently asked whether the ligament has the potential to heal and to be as strong as it was before the injury or whether surgery is inevitable. None of us are looking for a surgical case, but players may come in with their minds already made up. Some want surgery so badly that nonsurgical treatment won’t work. You might as well go ahead and fix them.
Dr. Bradley: I see a lot of younger players. If we confirm a partial tear, our protocol is that they’re not allowed to throw for 6 weeks and then we start therapy.
First, we look for a deficit in the kinetic chain. Then we go through pitching mechanics and shoulder kinematics, looking for motion deficits in the shoulder. After these evaluations and corrections, we focus on strengthening the core and the lower extremities.
Dr. Kelly: Does anyone use PRP injections for UCL injuries?
Dr. ElAttrache: Few studies have looked at this critically. The patients in Dr. Noonan’s study had partial tears and got better with simply allowing them to rest and heal. Whether those results can be enhanced with PRP or any other kind of biologic treatment has yet to be seen because none of the reported studies have a control group.
Dr. Bradley: We have some experience with using PRP and have found it to be a helpful adjunct for younger players with partial tears. We increased return to play rates from 50 percent to nearly 80 percent simply by using PRP as part of their initial treatment.
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