UCl Tear- Shohei Ohtani
“<Insert young pitcher phenom here> to have Tommy John surgery” is an ever increasing headline seen in sports today. It seems like whenever a new young pitcher enters the majors he is almost always destined to under-go Tommy John surgery, to the point where it becomes expected. From 2007 to 2014, 130 ulnar collateral ligament injuries of the elbow occurred in Major League Baseball players during the regular season, and It’s not just prominent in the majors either; between 2004-2008 26% of baseball athletes high school aged or younger under went Tommy John Surgery, compared to 7% in 1994-1998. It’s a headline seen way too much over the past few year, so I’m here to breakdown what it is, why it happens, and what the athletes are doing to get back on the field.
What is “Tommy John Surgery” and how does it happen?
It is the surgical process to repair a torn ligament in the elbow, called the ulnar collateral ligament. Tommy John was the first pitcher to undergo the surgery in 1974, where his career was thought to be over after he tore this ligament. After surgery, rehabilitation, and biomechanical correction from his Kinesiologist, he was able to return to the game and pitch until 1989, forever creating the “Tommy John Surgery” phenomenon.
In the elbow, there is a complex of ligaments that help improve stability of the joint and resist against forces that may damage or injure the elbow. On the outside there is the radial (lateral) collateral ligament, and on the inside there is the ulnar (medial) collateral ligament.
When excessive/abnormal forces occur in the elbow (or any other joint in the ody) for an elongated period of time, a series of small tears start to occur in the ligament. Over time, these small microtraumas accumulate, turning small tears into bigger and bigger tears, until eventually the ligament ruptures. These abnormal forces occurring at the elbow during throwing a ball is called valgus force,meaning that the elbow joint is excessively being forced inward towards the body, rather than staying in a neutral or straight line. As you can see above, the elbow is being forced into a valgus position, where the forearm is being cocked backwards while the humerus (upper arm) is moving forward, overly stretching the ulnar collateral ligament.
Why does it happen?
Valgus force at the elbow happens in all levels of throwers and is unavoidable, as it is part of the natural biomechanical motion. So why does it happen to some pitchers but not others? There are a few hypotheses out there:
- Throwing more Curveballs:
- Research has not shown a correlation between curveballs thrown and UCL injuries. However, proper mechanics is crucial for pitcher development and sustainability in the sport. Proper biomechanics with throwing a fastball should be developed prior to incorporation of breaking balls. One study has actually shown a decrease in shoulder/elbow injury with increased change up usage as less valgus/varus forces occur at the elbow.
- Increase in Innings:
- While there have been propositions of increased innings pitched=increased injury risk, and a subsequent “pitch count” in the MLB today, there is no substantial evidence to confirm or deny the claim. Anytime you throw more pitches with increased fatigue the injury risk increases but this threshold may be different for each athlete.
- Sport Specific Athletes:
- In our generation, baseball athletes -and other athletes- are playing their sport year round, rarely being involved in any other sport. While this is good for their skill development it is detrimental to their health. The constant throwing without any rest periods during the year fails to allow the body to heal in the ways necessary to sustain longevity in the sport. Older generations of MLB pitchers only used to throw 2-3 months in their adolescence. Now it is much higher.
Take home: Too much pitching + not enough rest/recovery/variation= Injury.
Rehabilitation process and treatment:
Recovery from an ulnar collateral ligament tear and the accompanying surgery is a 12 month process from operating room to the first pitch back. Initially, the surgery occurs when a tendon is taken from another muscle (called a tendon graft) and is then used to replace the damaged/torn ulnar collateral ligament.
During the post-operative phase (up to 3 weeks post-surgery) the goal is to promote proper healing and decrease pain/inflammation. Elbow and shoulder range of motion exercises and isometrics of the wrist and elbow are given along with icing instruction and brace wear. 1-2 months post-surgery is the period of increasing range of motion, continual improving of tissue healing processes and integration of improving and regaining muscular strength. Re-introduction to strength exercises is focused initially on the rotator cuff muscles, which are a group of 4 small muscles on the outside and back of the shoulder that help to stabilize the shoulder throughout different movements.
Once introduced to rotator cuff exercises, an exercise program called the ‘Throwers Ten’is introduced to start progressively loading the shoulder joint. I’ve attached the program at the end of the article if you are a throwing or overhead athlete wanting to improve your shoulder health.
2-3 months post surgery and the elbow has finally reduced its inflammation and the repaired tissue and new ligament are finally healing. At this point the athlete starts to focus rehab towards increasing strength, power, and endurance of the wrist/elbow and shoulder. This is done through the Throwers Ten program and other forms of exercises that emphasise different muscular contraction to force new muscle to be laid down around the joints, as well as scapular and core exercises. Closer to the end of the 4 month mark, the athlete can start to incorporate light sport activities to tolerance.
4-6 months post surgery is aimed towards continual increases in strength, power, and endurance. Incorporation of long tosses with the baseball and progression to throwing programs off the mound occur at 16 weeks. 6-9 months into the recovery is then focused on gradual return to competitive throwing, with the process taking even longer for a major league pitcher due to the importance of being absolutely sure the elbow is good to go.
What healthcare practitioners are involved?
After surgery, a triage of physiotherapists, chiropractors and kinesiologists are responsible for the planning and execution of exercise prescription and supervision as well as providing manual therapy to the muscles and joints to expediate the healing processes. While physiotherapists are often thought as exercise therapists and chiropractors are thought as ‘bone crackers’, this is simply not true in this day in age. Physiotherapists can undergo extra training to address joints manually through mobilization/manipulation, and chiropractors more often than not come from an exercise background -like kinesiology- and often apply rehabilitative exercises with each patient. Kinesiologists are involved in the biomechanical side of things, making sure the athlete is using proper biomechanics during their exercises and throughout their sport activity.
So, What can I do to prevent this?
Prevention always starts with a baseline knowledge and understanding, which you have just completed since you’re still reading this! The important thing is to make sure that you are a well-rounded athlete and even though you love to throw a baseball, you have to take care of the rest of your body to make sure it is strong and stable enough to withstand the amount of stress you’re putting through the elbow and shoulder joint. This ranges from upper back strength to improve shoulder stability, lower body strength to improve leg drive to decrease force needed at the shoulder, and shoulder stability. If a general strength program and the throwers Ten program is incorporated (attached at the bottom of this article) then you are well on your way to becoming a well-rounded, durable baseball player.
Thanks for reading, tune in next month for the most recent injury in the sport world. Email us with any questions or injuries you want to hear about next @ firstname.lastname@example.org.
Stay strong, stay heathy.
Doctor of Chiropractic, B.HKin.
- A good position statement on Tommy John surgery: http://www.asmi.org/research.php?page=research§ion=TJpositionstatement
- Throwers Ten program: http://www.elleboogkliniek.nl/wp-content/uploads/Throwers-Ten-Exercise-Program.pdf