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The Tommy John Procedure

The Ulnar Collateral Ligament of the elbow (UCL) has become a common topic among athletes and those interested in throwing.

by Paul D. Reynen, MD, Sanford Clinic Orthopedics & Sports Medicine

As the Major League Baseball Playoffs are going on, it might be helpful to review a bit about throwing and some of the associated problems. The Ulnar Collateral Ligament of the elbow (UCL) has become a common topic among athletes and those interested in throwing. There is no doubt that the diagnosis and treatment of this problem has increased significantly over the last 10-15 years. It may be related to the amount of throwing being done but also from the fact that it is recognized by more people and there is an awareness of a procedure to “correct” the problem.

The UCL is a band of tissue that supports the inner aspect of the elbow. It is necessary to allow an arm to cock back and throw hard. Other activities are usually handled pretty well with a bad UCL but this is variable among athletes. The injury that people are referring to is an isolated injury to the ligament that occurs with throwing. This can be broken down into 2 groups. The most common story is a pain or “pop” that is felt while throwing. Many athletes will have had some history of soreness in the area leading up to this event. The athlete will notice that they are unable to throw hard after this event. The second group is usually older and has gradually worn out the ligament over time. This is usually associated with other problems in the elbow as well, such as bone spurs, etc.

The diagnosis is made by the history, location of the pain and commonly by MRI (although this is not always accurate). Most treatment will consist of some form of rest and splinting of the arm and gradual return to throwing if able. This process would take about 4-6 months and unfortunately hasn’t been very effective. If the athlete is playing at a “high level”, many will opt for initial surgical treatment because of the increased odds of success and the fact that this will take 9-12 months in itself. The concern is that if they tried the non-operative route and failed and then did the surgery, they would lose two seasons instead of one.

There are minor variations in the technique but the idea is to repair the ligament with a tendon graft. It is an open operation although some will use the arthroscope to begin the surgery to further assess the elbow and ligament. The recovery process begins with rest and then motion and strengthening and gradually to a throwing program. The success rate (of returning to throwing) varies from the upper 60”s to mid 80’s percentile. The bigger question is how long are they able to compete following their return and at what level? Philosophically, different ages of athletes are handled differently. The questions come up with the younger athletes. If an athlete’s throwing technique causes them to overload their UCL at a young age, let’s say high school or younger, what would we expect will be the outcome of such a procedure? Will they recover enough and change their style enough to allow them to progress up through the levels and pursue their goals? Those are tough questions to answer and need to be discussed with your care giver.

Dr. Paul Reynen is an orthopedic surgeon for Sanford Clinic Orthopedics & Sports Medicine specializing in arthroscopic surgery of the knee and shoulder. Dr. Reynen serves as the team orthopedic surgeon for the University of South Dakota, Augustana College, Sioux Falls Pheasants and the Sioux Falls Skyforce.


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