Tommy John Surgery

Tommy John surgery is the colloquial name for a surgical procedure called an ulnar collateral reconstruction, or UCL. Designed to restore throwing ability in damaged elbows, the procedure has a storied history and a remarkable record of success. The expert surgeons at Plymouth Bay Orthopedics, in Plymouth, MA are masters of this procedure and can put you back on your game with confidence.

Why Is It Called Tommy John Surgery?

If not for the surgical procedure named after him, it’s doubtful that many would remember former Major League Baseball pitcher Tommy John. Beginning at age 20, John had a successful but unremarkable career for 10 years until he permanently damaged the ulnar collateral ligament in his pitching arm in 1974.

For most players of his time, this injury would have meant the end of John’s career. Fortunately for him, a young orthopedist, Dr. Frank Jobe, who had done prior work with John’s Los Angeles Dodgers teammates, had an idea for a new surgical technique based on transplanted tissue. What if the damaged UCL could be fixed by anchoring it with healthy tissue harvested from elsewhere in the body?

A Medical Breakthrough

Nobody knew what the clinical outcome of this radical idea would be back in those days. The surgery prevented John from playing for a year. But upon his return, something remarkable happened. The elbow not only held up, but the pitcher became even stronger. John went on to play for another 13 years with all-star success. Upon retiring at the ripe age of 46–unheard of for players in those days–John set a record for the most seasons played in Major League Baseball at 26.

It’s safe to say the surgery was a success. Today, the surgery is a safe and relatively common procedure in sports medicine, performed on athletes young and old.

Why Is It Needed?

Sports that involve a great deal of throwing, swinging or other impactful arm movements place tremendous unnatural repetitive strains on the various components of the arm. These include the shoulder and wrist, but most notably, the elbow. Sports that make these stressful demands on the elbow include baseball, tennis, and golf.

The ulnar collateral ligament is a thick band of tissue that serves as the major stabilizer of the elbow. It connects the humerus (upper arm) to the ulna, which is the large bone of the forearm. Over the course of years playing sports, often beginning at an early age, the strain of throwing a ball or hitting one with a racquet or club causes damages to the UCL. The tendon can become frayed, sustain small tears, or gradually become loose.

What Are the Symptoms?

There’s generally no mistaking the symptoms of significant damage to the UCL: the pain is typically severe enough to diminish athletic performance or even prevent it altogether. However, many athletes play with UCL problems without really knowing the extent of the damage or even that damage has been done. In the case of severe UCL tear, athletes may hear a popping sound. At that point, there’s little left to do but see the doctor and look into surgery. Other symptoms of UCL damage are more subtle and should also be seen by a professional.

Besides pain on the inside of the elbow, athletes with damaged UCL tissue may have the sensation of instability at that joint. One pitch may feel fine while the next one may feel like “something is loose” in their arm. Another symptom to look out for is numbness or a tingling sensation further down the arm into the hand. This is due to irritation of the long ulnar nerve, better known to the rest of us as the funny bone. There’s nothing funny about pain in this region.

Common Causes

UCL damage is essentially a result of repetitive stress. In the case of many aspiring athletes, the stress starts at a young age. As an example, nowadays Little League baseball participation often starts before the onset of puberty. Young bodies are still growing at this stage.

Subjecting the arm to constant strains of throwing, not to mention the twisting motions of the hand and wrist that account for spin and “breaking balls” can cause damage before the tissue is strong enough to sustain it. Moreover, today’s young athletes participate in year-round activities. Where at one time baseball season lasted only a few months a season, today young athletes may concentrate on their pitching for ten or even twelve months out of the year.

The Stage Is Set Early

These stresses on an adolescent’s elbow are well beyond what they can naturally tolerate. This has led to what doctors see as an epidemic of Tommy John surgery in younger people. Even if UCL damage has not become debilitating during these early years, the wear they produce on the elbow is already in place for eventual problems later down the road.

Who Is a Candidate?

Is this surgery only performed on athletes? The answer is no. In the case of athletes, the damage to the UCL is the result of chronic stress. Throwing hundreds of pitches per day or hitting dozens of forehand or backhand tennis strokes is bound to take its toll on the elbow.

However, the UCL can also be damaged by an acute event that causes sudden elbow injury. These high-stress episodes are not as common but can be just as disruptive. If you fall from a height and catch yourself or are involved in a car accident, your elbow and the UCL can loosen, rupture, or tear. The recommended repair is UCL reconstruction even if you’re not an athlete.

Are There Alternatives?

Before deciding if the surgery is necessary, your doctor may recommend rest and some rehabilitation exercises. Not all damage to the UCL necessitates the surgery, though in most cases, with continued activity, eventual surgery is likely. Anti-inflammatory medications may also be recommended for pain. Simple therapies to improve posture and throwing techniques may be imparted by sports medicine specialists.

Before Considering the Surgery

Besides rest and decreased activity, there are options for UCL damage that are non-surgical. These include specialized physical therapy, which is completely non-invasive, and injections into the elbow of platelet-rich plasma (PRP). PRP is a refined version of the body’s own platelets, which are a growth agent. PRP injections help damage tissue regenerate itself naturally and speedily.

In many cases, especially young people, these remedies are viable alternatives to surgery. They are not likely to permanently fix the problem for a professional athlete or someone that plans to become one. However, doctors caution that many young athletes, especially adolescents, have a good long think about whether invasive surgery and a year of rehabilitation is advisable. Little Johnny may want to be an all-star pitcher someday. Is it worth the surgery and recovery today?

Surgical Approaches

Reconstruction of the UCL begins with the surgeon making an incision on the inside (medial) of the elbow joint. The damaged ligament along this medial side is then replaced with tissue that has been harvested from elsewhere in the patient’s body. While the tissue for the “graft” can come from several areas in the body, the original surgery pioneered by Dr. Jobe used a tendon from the wrist.

The Docking Technique

In this common technique to replace the damaged UCL, the surgeon drills two holes in the ulna, which is the thinner of the two bones in the forearm. The surgeon also drills three holes on a bony protrusion on the inside of the elbow at the end of the humerus (the longer forearm bone). This bump of bone is called the medial epicondyle.

The three drilled holes in the medial epicondyle are arranged into a triangle. The holes that are drilled into the ulna create a tunnel that the grafted tissue is looped through. The surgeon then slides the tendon graft into the bottom hole of the triangle. The two holes at the top are used to pull the tendon graft through the tunnel using sutures that have been attached to the graft.

Keeping It All in Place

Using this threading and suturing technique, the surgeon pulls the grafted until the amount of provided tension is enough to hold the joint in position. The surgeon tests this by literally moving the elbow through its full range of motion while the patient is still under anesthesia. The surgeon then fine-tunes the tension on the sutures until he or she is satisfied that the tension is correct for the full range of motion. The procedure is completed by tying the sutures together in the final fixed position.

The Figure Eight Technique

Another common technique used by orthopedic surgeons is the figure eight. In this method, the graft is threaded through two pairs of holes instead of three: two in the ulna bone and two in the bulbous medial epicondyle. The graft is then woven through the holes in a figure-eight fashion, and two ends of the tendon are sutured to the tendon itself. This is the method the late Dr. Jobe used for his pioneering work in 1974, and the method is still in wide use today.

The Internal Brace

While the Docking and Figure Eight techniques are by far the most common methods of UCL reconstruction, a more recent repair technique has been cited for promising, especially in cases where the UCL damage is not severe. Called the Internal Brace, the procedure can be thought of as a repair as opposed to a reconstruction.

The Internal Brace solution uses a collagen (human protein-based) “tape” to secure and stabilize the loose UCL. Biologic agents such as the aforementioned PRP may also be used along with this technique. The advantages to this method are that surgery is lighter and recovery times can be faster. Moreover, there is no chance of any rejection of the grafted tissue (which is rare but not impossible) because there is no graft. While the Internal Brace is worth discussing with your doctor, a serious UCL injury will likely involve either the Docking or Figure Eight surgical technique.

What Are the Odds of Success?

When Dr. Jobe performed the first Tommy John procedure, he thought the odds of success might be 1 in 100. How wrong he was. Today, the success rate for the surgery routinely falls between 85-90% recovery. That’s great for those undergoing the procedure, but it’s important to understand what success means in these circumstances.

There is a serious misconception, mostly floated by zealous sports media, that players who recover from the surgery actually pitch better than they did before the procedure. Doctors warn that this is a fallacy, including the originator, Dr. Jobe. Whenever we damage part of our body, the goal is to recover to the point where we were before the injury. This surgery will not make pitchers throw harder or forearm smashes any faster. Successful surgery brings the patient back to their pre-injury capabilities.

Better Than Ever?

Many athletes and their coaches insist that they throw harder and better after their Tommy John procedure. Why? Doctors are unanimous in their assessment that the comparison is moot. By the time an athlete needs UCL reconstruction, they have been playing with a damaged arm: a repaired arm will certainly perform better than before.

Moreover, doctors agree that the improved conditioning that athletes undergo during their rehabilitation is a big contributor to their post-surgical success. These changes, along with the surgical repair, contribute to the impression of “better” performance.

What Are the Recovery Stages?

Recovery from Tommy John surgery is time-consuming but straightforward. The surgery itself usually means just an overnight stay in the hospital. Full rehabilitation, where the player can perform at their new 100% of ability usually takes 12-14 months for a pitcher and about half of that time for another “position” player that doesn’t use their arm as frequently.

The surgery is always followed by extensive rehabilitation therapy. For the first few weeks following surgery, the grafted tissue is extremely fragile, so the elbow is usually immobilized in a brace. This keeps the elbow stable and held in place so that the graft can gain a foothold and start to heal properly.

Rehabilitation Is Key

Once the elbow no longer needs to be immobilized, the next step is physical therapy. The goal here is to regain strength in the arm and achieve the full range of motion. For some patients, particularly youngsters, this period can be surprisingly brief, lasting only 6-8 weeks. This short period, however, does not mark the full recovery, especially for a competitive athlete. Most professional players don’t play again competitively for at least a year.

How Can I Get Started?

Despite glib headlines from the sports media that frames Tommy John surgery as a “so what?” procedure, this is a genuine invasive surgery that should not be undertaken lightly. This is especially true for young athletes whose age and body development should be taken into account with the help and advice of an orthopedic specialist. Further, while the techniques for Tommy John surgery are well-established, two important components factor in greatly in a successful outcome.

First is the willingness to adhere to the rehabilitation regimen. For many experts, this is just as important to the outcome as the surgical technique itself. The second and most important component is the skill of the surgeon who will perform the procedure. If you’ve been experiencing elbow pain that needs medical attention, call Plymouth Bay Orthopedics, in Plymouth, MA for a consultation. Our highly experienced, world-class surgeons can bring your game back to you.