An astounding thirty-one major league pitchers underwent Tommy John surgery in 2012 and another, 40 year-old Jose Contreras, was diagnosed in June with a tear of the ulnar collateral ligament (UCL) and flexor pronator in his throwing elbow. Three other pitchers continue to ramp up their rehab from UCL reconstructions performed in 2011 by pitching this month in simulated games, in the instructional league and in the minors. These figures do not include those who returned to major league competition in 2012 following earlier surgeries.
The ulnar collateral ligament is the primary stabilizer of the elbow. Pitchers place undue stresses on the medial (inner) elbow, and this excessive loading of the region can impact not only the UCL, but can also create inflammatory conditions in all of the structures in the area. These include the wrist flexor muscles (which are in the forearm but attach at the inner elbow), the forearm pronators (which turn the palm downward), the elbow joint capsule, and the ulnar nerve. The repetitive demands of pitching and the nature of the motion itself – particularly the acceleration phase – are the primary culprits.
The end result of moderate UCL sprains (Grade 2) is laxity (looseness) of the ligament, which results in joint instability. This instability causes even greater stress on the surrounding tissues. Even after the cumulative trauma of less significant Grade 1 injuries (microtears), ligaments may be weakened and tissues prone to inflammation. At worst, they could tear further. Additionally, other degenerative changes, such as bone spurs may result. A severe sprain (Grade 3) is actually a complete tear of the ligament. These may occur traumatically, as with one pitch as claimed in Stephen Strasburg’s case, or in the event of elbow dislocation. However, for many, earlier injuries set the stage.
Dr. David Altchek, orthopedic physician for the NY Mets, and co-chief of the Sports Medicine and Shoulder Service at New York’s Hospital for Special Surgery, pioneered a radical modification of the Tommy John procedure that is now the gold standard. The original surgery, first performed by Dr. Frank Jobe in 1974 on Tommy John, then of the LA Dodgers, involved using a tendon graft harvested from the patient and weaving it in a figure eight pattern through channels created by drilling three holes into the bone. To do so, muscles were detached and the ulnar nerve had to be moved. The newer technique, known as the docking procedure is less invasive, entails splitting the muscles rather than detaching them, requires that only one hole is drilled and allows the ulnar nerve to remain in place. Success rates exceed that of the traditional approach, though pitchers still are progressed cautiously and on average return to competition just prior to the anniversary of surgery. Success is determined by restoring pre-injury levels of performance rather than time to return.
What are your thoughts on Washington’s decision to limit Strasburg’s innings in his first season back from Tommy John surgery?
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