Strasburg Likely Needs Tommy John Surgery
Washington Nationals star rookier pitcher has a torn ligament in his right elbow and will likely need Tommy John Surgery. What is this and what does it mean for his career?
The elbow is a hinged joint, with many structural supports on the inner and outer parts of the joint. Three bones make up the elbow joint: the humerus (upper arm bone), the ulna (a forearm bone), and the radius (another forearm bone).
On the inner aspect of the elbow, the medial or ulnar collateral ligament (UCL), gives stability to the elbow. On the outer part of the elbow, the lateral or radial collateral ligament (RCL) and annular ligament provide stability for the elbow. A lot of stress and force passes through these structures with certain activities. The UCL must withstand a lot of force with pitching. The motion of pitching produces forces which try to separate the ulna from the humerus. The UCL prevents these bones from moving apart.
In addition to these ligaments, the muscles of the tendons that bend and flex the wrist attach to the humerus on the inner part of the elbow. The muscle attachment to the bone can be stressed with repetitive, high energy motions and forces.
Injury to the elbow is common in pitchers. The repetitive motions, stresses, and forces that go through the structures of the elbow place it at risk for injury. The common injuries to the elbow that happens in the adult pitcher include a strain or tear of the UCL, inflammation and degeneration of the attachment site of the wrist flexors (medial epicondylitis), or an osteochondral defect (OCD) of the elbow joint surface. An OCD is where a chunk of bone and cartilage are divoted out of the joint, similar to a pothole in a road.
Most pitchers with thrower’s elbow will experience pain and swelling on the inner part of the elbow. At times there is also loss of strength and pitching velocity. There will be tenderness and pain over the UCL or the attachment site of the wrist flexors. If the UCL is torn, these players will also feel instability in the elbow with throwing activities. If there is an OCD, players may describe locking or catching of the elbow joint.
Treatments are tailored the structure that is injured. A pitch count is used in baseball to minimize fatigue and stress to these elbow structures.
UCL strain – These players can be treated with rest and anti-inflammatories. Changing the mechanics of throwing can minimize future injury to the UCL. Physical therapy is used to strengthen and stretch the muscles on the inner side of the elbow.
UCL tear – These players will require what has become known as Tommy John Surgery. This surgery is a reconstruction of the UCL. This restores the stability of the elbow.
Medial epicondylitis – This can be treated initially with rest, anti-inflammatories, straps, and physical therapy. At times, a steroid injection can help calm down the pain. If an individual fails these conservative options, then surgery is needed to remove the painful tissues and reattach the tendon to the bone.
OCD – An OCD usually develops on the outer aspect of the elbow. An elbow arthroscopy can be used to remove the loose cartilage and bone. Since the human body is unable to regrow cartilage, the OCD lesion is cleaned and drilled to stimulate scar tissue to fill in the “pothole.”.
WHEN TO SEEK MEDICAL CARE
Pitchers who have persistent pain, swelling, or difficultly pitching should seek medical attention.
RETURN TO ACTIVITIES/OUTCOMES
Most athletes with a tear of the UCL will need surgery to have a chance at getting back to playing competitive sports. Recovery will be prolonged and extensive requiring months of physical therapy. Strasburg will likely be throwing again by December or January. However, most athletes with this injury struggle to return to their pre-injury form.
For a video animation of “Throwing Injuries of the Elbow”, please see the “Education” tab of my website. Click orthopaedics, then elbow, then conditions, then throwing injuries of the elbow.
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