Ulnar Collateral Ligament Injuries in Athletes - Tommy John Surgery

Medial Elbow Injuries in Throwing Athletes

throw overuse
Tommy John surgery can be a serious problem for throwing athletes. Photo © Piccillo Photography

Tommy John may be better known by younger baseball fans not for his accomplishments on the pitcher's mound, but for the surgical procedure that bears his name.  The fear of baseball pitchers and other throwing athletes are injuries to the ulnar collateral ligament of the elbow.  The ulnar collateral ligament of the elbow is on the inner (medial) side of the joint, and helps to provide stability to the elbow joint.

  When throwing, significant stress is placed on the ulnar collateral ligament, and injuries can occur to the ligament.

In recent years, injuries to the ulnar collateral ligament, and the need for Tommy John surgery, has become increasingly common.  There is concern among physicians that the injury rate is increasing, possibly as a result of baseball pitchers throwing too much, too often.  While many coaches are aware of the importance of limiting pitch counts, it's hard to know how much is too much.  Furthermore, summer baseball has evolved into a year long activity for many young athletes, further subjecting the elbow to repeated stress.

Symptoms of UCL Injuries

The most common symptom of an ulnar collateral ligament injury is pain directly over the ligament on the inner side of the elbow.  However, not every elbow pain in a throwing athlete is a UCL injury, and it's important to have a careful examination by a physician skilled in throwing injuries to determine the cause of the elbow pain.

  The most common symptoms of ulnar collateral injuries include:

  • Pain, most commonly in the 'late cocking' phase of throwing (when the ball is up, and behind the head)
  • A 'popping' sensation when the pain begins
  • Numbness or tingling in the hand and fingers
  • Decrease in pitch velocity

As stated, there are other causes of the symptoms.

  Specifically, tendinitis of the muscles on the inner side of the elbow (the wrist flexor muscles) is the most common problem to cause similar symptoms.  Usually tendinitis begins more gradually than UCL injuries, but they are commonly confused.  Ulnar nerve problems can also cause pain and nerve symptoms in the same area.

Preventing UCL Injuries

Tommy John surgery can require over a year of recovery, and is not a guarantee to return to the same level of throwing, so the importance of prevention of UCL injuries is paramount.  The USA Baseball Medical/Safety Advisory Committee has made specific recommendations about how many pitches different age athletes should be limited to throw over the course of a game and a week, and how much rest they should have after throwing.  All coaches at every age level should be familiar with these limits.

Any early signs of elbow discomfort should be treated with urgency.  Throwers who develop elbow pain should be removed from competition immediately and assessed by someone trained in the common causes of elbow pain.

  A throwing progression should always be performed before returning to pitching, even if the cause is thought to be unrelated to an injury to the UCL.

UCL Injury Treatment

Most athletes who sustain an acute injury to the UCL will try nonsurgical treatment first.  Immediate resting of the painful elbow, followed by a closely monitored physical therapy evaluation should proceed.  Physical therapy should include a careful assessment of throwing mechanics to determine methods to lower the stress placed on the injured ligament.

Surgical treatment to perform a Tommy John procedure is done by reconstructing a new ligament, not repairing the damaged ligament (similar to ACL reconstruction).  The new UCL is made from a tendon in the forearm called the palmaris longus tendon.  Most, but not all, of us have a palmaris longus tendon, but we don't need it.  If you don't have a palmaris longus tendon, there are other tendons that can be used for making a new ligament.

Once the graft has been obtained, your surgeon will make small drill holes above and below the elbow joint where the UCL attaches to the bone.  The tendon graft will be pulled through the holes, and wrapped in a figure-of-8 style and sewn back upon itself to create the new ligament.

Rehabilitation after Tommy John surgery takes almost a year.  Most athletes do not begin any throwing until at least 4 months after surgery, and the progression is slow.  Some athletes return to full strength by 9 months, although many take more than a year to fully recover.

Sources:

Bruce JR and Andrews JR. "Ulnar Collateral Ligament Injuries in the Throwing Athlete" J Am Acad Orthop Surg May 2014 ; 22:315-325.; doi:10.5435/JAAOS-22-05-315

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