Tommy John Surgery (Ulnar Collateral Ligament)
Tommy John surgery refers to the surgical procedure to repair or reconstruct an injured elbow ulnar collateral ligament (UCL). The surgery is named after the former Los Angeles Dodger pitcher, Tommy John, as he was the first to undergo this type of procedure in 1974. Since that time, the procedure has become extremely common with about 10% of current major league pitchers having undergone the procedure. During UCL reconstruction, the torn or injured ulnar collateral ligament is replaced with a tendon taken from somewhere else in the patient’s body. Presently tens of thousands of athletes have been able to return to their previous level of play thanks to the surgery. However, even better news is that many athletes with an injured ulnar collateral ligament may get better with conservative treatment.
The ulnar collateral ligament connects the humerus or upper arm bone to the ulna which is a bone in the forearm. Though anyone can injure their ulnar collateral ligament from repetitive stress or trauma, these injuries typically occur in throwing athletes due to the fact that throwing motions place extreme stress on the ligament. Each throw of the baseball approaches the ultimate load to failure of the ligament. The reason the ligament doesn’t tear with each throw is due to the other stabilizing muscles in the shoulder and the elbow. However, over time, the UCL can develop microscopic tears that progress to larger tears. Even progressive stretching and lengthening of the ligament can make it insufficient. While this most commonly affects baseball players, javelin throwers, tennis players, gymnasts, football players, and wrestlers are often affected as well.
The good news about UCL injuries is that they don’t typically affect the activities of daily living, as this ligament plays a highly specialized role during very few activities. That said, when athletes injure their ulnar collateral ligament, symptoms during their attempted play may include pain on the inside of the elbow, a sense of looseness or instability of the elbow and a decreased ability to throw as well as they could to prior to the injury.
The diagnosis is made by taking a thorough history and performing a physical examination. On exam, patients will have pain along the course of the ulnar collateral ligament and their elbow may feel more unstable than their opposite, unaffected elbow. X-rays are obtained to rule out any bony injuries and to look for bone spurs or loose bodies in the elbow. MRIs are typically the gold standard to confirm the diagnosis.
First line treatments include rest from the offending sport, anti-inflammatory medications and structured physical therapy. Physical therapy will focus on strengthening the muscles around the elbow and shoulder to compensate for the injured ligament. If non-operative treatment fails, surgery is indicated. Again, this involves taking a tendon from elsewhere in the body and using it to replace the injured ligament. It is done by weaving this tendon graft through the bone in the forearm and the humerus. While the surgery only takes about an hour, the recovery is lengthy. It typically takes about four months to re-allow athletes to return to throwing. They don’t start pitching until about seven months after the procedure and high level athletes don’t get back to playing competitively until about nine to twelve months after the procedure. When surgery is indicated and performed, the good news for athletes is that successful outcomes have been reported in about 90% of cases with athletes getting back to their previous level of play.