Fix Your Throwing Arm: Tommy John’s Surgery Explained

tommy john's surgery

As of 2018, a total of 455 Major League Baseball players have undergone Tommy John’s Surgery since 1974. This surgery has helped more people than only professional athletes. In 2011, more than half of the patients who underwent tommy john’s surgeries were teens ages 15 to 19.

By 2017, a study showed that of 5,300 college-level athletes, 134 underwent the surgery. This surgery has gained popularity as the techniques have improved.

It is important to understand the procedure before you have it.

Who is Tommy John?

If you love baseball, then you’ve probably heard the term Tommy John’s surgery. Many of our favorite players of all ages have had this surgery.

Thomas Edward John Jr. was one of the most dependable starting pitcher in the Majors from 1965 to 1973. In 1978, Sports Illustrated wrote that “the sore arm is endemic to pitching.” It was not unusual for a pitcher’s arm to hurt, so people accepted it as part of the life.

The effort involved in throwing a baseball 100 times or more over 3 hours, tears at bone and muscle. A pitcher can’t function with a sore arm and this hurts his career. They always said that if you ever go under the knife, your career was over.

In 1974, Tommy John was in the middle of his season with a 2.59 ERA with the Dodgers. In the 3rd inning, he felt a twinge in his arm. He stated it was “the strangest sensation I had ever known…as if my body continued to go forward and my left arm had just flown out to right field, independent of the rest of me.”

Tommy John had to undergo surgery. Dr. Frank Jobe began the operation planning to repair the medial ulnar collateral ligament (UCL). To Dr. Jobe’s surprise, John didn’t have enough UCL to repair.

Another common surgery was to harvest a ligament from the wrist and use it for wrist and hand repairs. No one had done this on an elbow. Dr. Jobe decided to take the chance and he used the wrist ligament to replace the UCL.

After rehabbing the elbow, Johns returned to the Majors. He threw 207 solid innings in 1976 and finished second in the National League Cy Young voting in 1977. He pitched until the age of 46.

Overview of Tommy John’s Surgery

The medical name for Tommy John’s Surgery is Ulnar Collateral Ligament Reconstruction. This surgery is often performed to repair a torn UCL inside the elbow.

It uses a tendon from someplace else in the body or a donor tendon. This surgery aims to stabilize the elbow, decrease or eliminate pain, and restore stability and function.

The surgery is often performed as an outpatient procedure. It is done with the patient under general anesthesia. The surgery lasts from 60 to 90 minutes.

Anatomy of the Elbow Joint

To understand the UCL injury and surgical repair, you need to know the parts of the elbow and how they work.

The elbow joint brings together the humerus, the ulna, and the radius. The radius is the forearm bone on the thumb side that moves when you rotate your hand.

The elbow combines the properties of a hinge and pivot joint. The hinge part allows the arm to bend and straighten. The pivot part allows the lower arm to rotate and twist.

At the top end of the ulna, you have the olecranon. This bony point of the ulna makes the “elbow bone” that most people feel under the skin.

On each side of the elbow, thick ligaments, called collateral ligaments, hold the elbow joint together. This prevents the elbow from dislocating.

The ligament on the inside of the elbow is the medial ulnar collateral ligament (UCL). It connects the inner side of the humerus to the inner side of the ulna. This is the ligament that takes the most stress with overhand throwing.

If you have a tear in the UCL, you can still move your arm. But you lose the ability to throw with any force.

The elbow also has several muscles, nerves, and tendons that cross here. The flexor/pronator muscles of the forearm and wrist start at the elbow. They are important to stabilize the elbow during throwing.

The ulnar nerve crosses behind the elbow. It controls the hand muscles and provides sensation to the last 2 fingers (the ring and pinkie fingers).

Who Is at Risk for UCL Damage?

Repetitive stress or trauma to the elbow can result in UCL damage. People who throw often experience UCL injuries dues to the repetitive twisting and ending motion placed on the ligament under extreme stress.

When these motions continue, the ligament many develop small and/or large tears. The UCL can also become stretched to the point that it no longer holds the bones in place.

With time, these repetitive motions can also lead to swelling, cartilage injuries, bone spurs, as well as the UCL damage.

People at risk include those involved in:

  • Tennis
  • Soccer
  • Softball
  • Baseball
  • Football
  • Wrestling
  • Cheerleading
  • Gymnastics
  • Javelin throwing
  • Lacrosse
  • Golfing

It is important to understand your risk. Contact a physician if you experience elbow symptoms. An early diagnosis can lead to treatment before further damage occurs.

Symptoms of a UCL Injury

If you notice any of the following symptoms, don’t wait. Early intervention is always better in the long term.

  • Weak hand grip
  • Tingling or numbness in the pinky or ring finger which signals ulnar nerve problems
  • Tingling in the hand
  • Pain on the inside of your elbow
  • Stiffness in the elbow
  • Swelling on the inside of the elbow
  • Instability or a loose feeling in the elbow
  • Decreased ability to throw a ball or other object

Contact your physician or healthcare provider if you notice these symptoms.

UCL Reconstruction Explained

The following describes the step-by-step procedure followed for the UC reconstruction.

Graft Harvesting

Sometimes a donor graft is used which has been irradiated to prevent reactions to it. If not, a tendon from another part of your body is harvested. The graft tendons often come from the:

  • Palmaris longus tendon from the forearm
  • Hamstring tendon
  • Big toe extensor tendon

The physician makes the choice based on the best outcome for the patient.

Cleaning the Joint Out

The surgeon begins by making a 3 to 4-inch incision on the outside of the elbow. This allows access to the elbow joint.

The muscle and other tissues are then moved aside. The surgeon may, instead, use a muscle-splitting technique to minimize trauma to the muscles. The ulnar nerve is still often moved.

Once the surgeon has a full view of the UCL, he/she can assess the damage.

The surgeon removes any damaged tissue. If you have enough UCL left, the surgeon may attach it to the graft. The goal is to reinforce the structure.

Securing the Graft Inside the Elbow

The next step involved attaching the new tendon. Holes are drilled in the humerus and ulna bones. The surgeon then threads the graft through these holes.

Several techniques are used to thread the tendon through the bones. The docking technique and the figure-eight technique are the most common.

The surgeon closes the incision and the procedure complete.

Who Benefits from UCL Repair Surgery?

UCL repair surgery can help individuals with UCL tears due to overuse. This surgery isn’t performed for a single traumatic event.

The most common candidates for surgery include baseball pitchers, other athletes who often bend their elbow, or individuals with lifestyles or jobs that put excess stress on the elbow.

Risk and Complications Associated with UCL Repair Surgery

As with all surgeries, there are risks for complications. These risks include:

  • Infection
  • Anesthesia reactions
  • Nerve damage
  • Blood vessel damage
  • Temporary or permanent numbness or weakness
  • Stretching or rupturing the graft
  • Complications at the graft harvest site

Patients can also experience ulnar nerve irritation.

Ulnar Nerve Neuropathy

The ulnar nerve passes through the inner side of the elbow where the UCL resides. It may get moved during surgery causing ulnar nerve problems. The ulnar nerve may need to brought to the front of the elbow joint to prevent further irritation.

Ulnar neuropathy describes a sensory and muscular shrinking or atrophy. This condition may result from compression or entrapment of the ulnar nerve.

The pressure on the nerve changes the normal feeling in the last 2 fingers. You may experience numbness and/or tingling.

The ulnar nerve is often called the “funny bone”. This nerve interacts with the most important muscles of the hand. If this condition goes untreated, weakness and irreversible muscle atrophy can occur.

If you notice these symptoms, even separate from having UCL repair surgery, contact your doctor immediately. Early treatment can prevent serious, long-term outcomes.

Rehabilitation After UCL Repair Surgery

The rehabilitation process after UCL repair surgery involves 3 phases. The length of each phase of therapy for an individual depends on how fast the tissues are healing.

Immediate Post-Operative Phase. A brace secures the elbow to keeps the elbow at a 60 to 90-degree angle. The goal is to protect the tissue as it heals and decrease swelling. Physical therapy focuses on your wrist, fingers, shoulder, and biceps to prevent muscle loss and weakness.

One to Two Weeks Post-Op. You may begin moving the elbow joint. You may have a hinged brace that locks at specific angles when you are not exercising. An arm sling can help with comfort. Your therapy goal focuses on gradual increases in your elbow movement, called range of motion.

At the end of the 1st month. You begin the work to fully extend your elbow and eventually stop wearing the brace. You should achieve full range of motion with physical therapy in 2 to 4 months after surgery.

Athletes may need longer rehabilitation before returning to sports. The average return, for example, to throwing, is often 6 to 9 months after the surgery. It is important to maintain a strength and stretching program to maintain your whole-body strength and endurance.

Questions to Ask Your Doctor Before Having UCL Repair Surgery

Preparing a list of questions to ask your physician before a procedure is always wise. This helps to make sure you understand the procedure and what to expect for your recovery and prognosis. This list can provide questions that you may not have thought of.

  • Why are you recommending this procedure?
  • Are there alternative treatments available?
  • How will this procedure help the pain?
  • How will this procedure help function and mobility?
  • How long will the benefits of the procedure last?
  • Are there any potential complications?
  • Can anything help to decrease the risk of complications?
  • How many of these procedures have you done?
  • How many of them experienced complications?
  • How is this procedure done?
  • Where will the incision be and how long will it be?
  • Will the surgery solve the problem?
  • Is it possible that future surgery will be needed?
  • What percentage of patients improve after the procedure?
  • What will happen if the surgery isn’t done?
  • Who is a good physician for a 2nd opinion?
  • What tests or medical evaluations do you need prior surgery?
  • What kind of anesthesia will you use?
  • Will you use a donor graft or a graft from another part of the body?
  • What part of the body will you get the graft from?
  • Will you order physical therapy after surgery?
  • How long is the wait before returning to work?
  • Are there materials explaining the surgery?

Never hesitate to ask questions. Make sure the surgeon marks the elbow he/she will operate on before you receive anesthesia. This ensures that the correct elbow receives the operation.

Are You Experiencing Hand, Wrist, Arm or Elbow Problems?

If you are concerned about pain, weakness, numbness, tingling, or decreased function do not wait. Our office includes a team of physicians who specialize in hand, wrist, arm, and elbow problems. We can talk about your concerns, answer questions, and evaluate your problem.

If you need treatment, we will make the treatment plan together. We want you to be comfortable with the plan of care. Do not hesitate to ask questions.

Visit our site to read more articles like this one about Tommy John’s surgery. Contact us today to discuss your health concerns.

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