Elbow Injuries

Ucl reconstruction (tommy john surgery)

Years ago if a thrower tore their UCL it was the end of their career. However, Dr. Frank Jobe invented an operation that rebuilt the torn ligament by replacing it with a tendon from the forearm. It worked, and has become a well-known surgery among pitchers. The technique has been refined, but the principle has remained the same—a tendon is woven back and forth between the bones (ulna and humerus) of the elbow to fabricate a new ligament. This is not an arthroscopy surgery, but rather an open surgery. Over the years the incision has become smaller. 

The ligament sits under the flexor tendon on the inner side of the elbow. This tendon must be split  or  moved  out  of  the  way  to  get to the ligament. The ulnar nerve, a

Years ago if a thrower tore their UCL it was the end of their career.

major nerve around the elbow, is nearby and must be protected. Holes are drilled in each bone where the ligament normally attaches, and the tendon is inserted into the holes. There are a few choices for the source of the tendon. Usually I will use a tendon from the forearm (palmaris) which has essentially no function so it is not missed after removal. However, not everyone is born with this tendon.  In those individuals I will use either a tendon from their knee (gracilis, one of the tendons I use for ACL reconstruction in the knee) or a tendon from an organ donor (“allograft”). These tendons all provide a strong ligament replacement, and the choice is determined by the athlete'’ preference after we discuss the pro’s and con’s.

       ucl tunnel                              ucl graft 1                  tradition graph placement

Once secured in place the tendon must be given a chance to heal to the bone. Once this has occurred, the tendon must then mature to become strong enough to tolerate throwing. It takes about 6 weeks for the ligament to heal to the bone, and about 3 – 4 months for it to mature enough to tolerate even easy throwing. So, after the surgery I restrict the patient’s movement, allowing gradually increasing motion until 6 weeks post-op. At that time, hopefully the elbow motion is full. Light tossing can begin 3 – 4 months after the surgery. The athlete gradually progresses his/her throwing, hopefully reaching the mound by 5 – 6 months post-op. While all athletes think that they will have fastest recovery  ever, the truth is that it takes at least 6 months to resume playing catcher or pitching. There are often setbacks during the journey back to pitching. Many times it takes a full year to return to the pre-injury level of competition. This is because it takes time to build arm strength after so much time off, plus the ligament must continue to mature. Remember, the forces on the UCL while throwing are among the highest ever measured and the ligament and arm must be given ample opportunity to strengthen. In our study of professional baseball players, Dr. Jereb and I found that players who had undergone UCL reconstruction before they were drafted and had recovered enough to get drafted had an 80% chance of playing at least 4 years of professional baseball without serious elbow problems. Another study showed that a high school pitcher has about a 70 -–75% chance of returning to that level of baseball after UCL reconstruction, and major league players had a >80% chance of returning to major league ball after this surgery. Though the recovery time remains long, this is quite an improvement compared to the days before Dr. Jobe invented this surgery. What used to a career-ending injury is now usually a repairable injury.

The Graft is Placed in

Tunnels Drilled in the

Bones of the Elbow

There seems to be a correlation between throwing curveballs and sliders at a young age (under 14 yrs) and the later need for UCL reconstruction. For years leading baseball doctors have recommended against throwing breaking breaking pitches during the peak growth years, and now there are some studies that strongly support this (Andrews J,  AJSM 2004; Chandler J, Professional Baseball Athletic Trainers Society Proceedings 2004). The latter study is posted on my www.drlintner.com for you review. In essence, if your pitchers are throwing curveballs and/or sliders at 12 and 13 yrs of age, they have a higher chance of needing major elbow reconstructive surgery when they are in high school.

Brace Worn after Surgery

For more information, contact Dr. David Lintner in Houston at 713.986.5560. Also, on Dr. Lintner’s website you can find detailed information regarding the postoperative rehabilitation after UCL reconstruction.

ucl mri (click on thumbnail to enlarge)