Dr. John talks about The surgical procedure to fix a torn ligament on the inside of the elbow ( Ulnar Collateral Ligament aka UCL) has been nicknamed “Tommy John Surgery”. The problem is very common in throwing athletes, mostly baseball pitchers, though a recent NFL playoff quarterback injured his UCL when the elbow ligament was stretched during a tackle.
Dr. John talks about The surgical procedure to fix a torn ligament on the inside of the elbow ( Ulnar Collateral Ligament aka UCL) has been nicknamed “Tommy John Surgery”. The problem is very common in throwing athletes, mostly baseball pitchers, though a recent NFL playoff quarterback injured his UCL when the elbow ligament was stretched during a tackle.
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Speaker 2:Hello and welcome to the Bone and Joint Playbook with Dr. John s tips for pain-free aging. Dr. John S is a board certified orthopedic surgeon with over 35 years experience in the Dayton, Ohio area. He is also a clinical fellowship trained surgeon in total joint replacement from Harvard. Today's topic is the big 10 of common foot and ankle problems. This episode is brought to you by
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Speaker 4:Well, hey folks, it's been a while since we've been here. This is Terry O'Brien with Tri-Level Productions, and this is another episode of the Bone and Joint Playbook with Dr. John Erst. Hello, Dr. ERs.
Speaker 5:Hi Terry. How are you?
Speaker 4:I'm good. It's been a while since we've been down here.
Speaker 5:It's great to be here though. This is, uh, February of 2023 and this is when baseball pitchers and catchers report for spring training. And in all baseball team fans, hearts, hopes springs eternal. Well,
Speaker 4:You know, you're a baseball fan. You've been playing baseball for how long?
Speaker 5:About 50 years I have to say.
Speaker 4:All right. And today's topic is of one that's near and dear to your heart because of baseball. What is it?
Speaker 5:It's gonna be all you need to know about Tommy John's surgery.
Speaker 4:Tommy John's surgery. Okay, I I gotta ask, what is Tommy John's surgery and why do they call it Tommy John's? John's surgery?
Speaker 5:Well, let's call that because the first patient to have this surgery was named Tommy John. He was a pitcher for the Los Angeles Dodgers in the 1970s, and he had suddenly lost his ability to throw the ball effectively. His arm was sore at the elbow and his velocity had decreased. Batters were hitting his pitches better and he went to a doctor in Los Angeles, a sports doctor, Frank job, who told him, I think I have an idea on how to fix your problem.
Speaker 4:And what did, uh, what what did they do to fix his problem?
Speaker 5:He said, your problem is that you've stretched a ligament on the inside of your elbow. It's called the owner Collateral ligament. And we're gonna mercifully abbreviate that UCL for the rest of this podcast. The UCL is like a ropey structure that holds the elbow. So it just bends and straightens up and down. That's what a knee does. That's what your elbow does. If that ligament gets stretched much like a rubber band, then it allows the elbow to hinge open awkwardly. And that puts a stretch on one of the funny bone nerves on the inside of the elbow called the owner owner nerve. Once that happens, the elbow is unstable or wobbly. And when a pitcher throws with a stretched out ucl, they get a zing or a tingle in their finger, usually the smaller ring finger and it, it hurts or it's uncomfortable, they lose their velocity. The pitchers, um, are unhappy, their coaches are unhappy. The only people that are happy are the other team's hitters
Speaker 4:<laugh>. So is it only a pitcher condition?
Speaker 5:No. Uh, it happened, uh, a few weeks ago in a championship football game in the nfl. One of the quarterbacks got his arm stretched awkwardly where it stretched that inside elbow ligament made it unable for him to continue throwing passes, which is why his team probably lost cuz they had to run the ball in the whole second half. And that's probably why the Philadelphia Eagles were in the Super Bowl this week because the other team's quarterback injured his ucl, which we didn't know until further testing from the doctors and tests, uh, bore out that diagnosis.
Speaker 4:So back in the seventies when they did this operation for the first time, was it successful? Could he come back and play baseball again?
Speaker 5:It was, uh, extremely successful, which surprised the surgeon and the baseball community because this was a career ending injury, um, the patient.
Speaker 4:So up to that point, people would, that's, that's the last thing they would do.
Speaker 5:And, and if you remember a podcast on the anterior cruciate ligament tears called the acls, that injury also ended somebody's football career or athletic career. Gail Sayers some of the more famous sports players in the seventies and, and before basically did not have the opportunity to have a good repair like we do these days for that injury having a repair that Tommy John had allowed him to return to baseball. He pitched extensively after that up to 12 years plus he retired as the seventh winningest left-handed pitcher in Major League history. So after his surgery, he not only was, um, able to pitch again, he attained his previous velocity and was very effective in resuming his pitching career.
Speaker 4:So one of the questions I asked you earlier, and I was, I think it'd be worth mentioning, is can it improve if I'm pitching 89 miles an hour, can I go 93 miles an hour?
Speaker 5:Initially, pitchers that were successfully rehabilitated after the surgery were thought to be pitching faster. A recent study looking at the last decade of baseball with these, um, radar guns has found that their pitches are about where they were before the surgery. They're not any faster, but as we said, they were losing velocity because they were having pain when they threw. So they had actually decreased their velocity and therefore it looked like they were throwing faster afterwards. But they, they pretty much get all, all of their speed back on four different kinds of pitches. And if you're a baseball pitcher throwing sliders, fast balls, curve balls and changeups, you, you need to have an idea of how fast that pitch will go because that varying, uh, a pitch speed and location is how pitchers get batters out.
Speaker 4:So let's, let's talk about, because I think it's important before we get into the details of what goes on in a Tommy John surgery, is how does it occur? Is it, is it, is it done by throwing the baseball wrong? Is it it's high school kids or high school kids, uh, seeing this more and more because of the fact that they're throwing wrong?
Speaker 5:Well, that's a great question, Terry. It's actually even before that. So it's really a little league problem. Uh, the best pitcher in little league pretty much find, finds the coach's heart and he gets the mound quite often.<laugh>, what we found is pitch count, which is how many pitches a pitcher throws in a given week is a huge determinant of whether that elbow is going to get injured later in a pitching career. The second thing is, as you said, the type of pitch they throw. So when you throw a curve ball or what's called a slider, it makes the ball, uh, spin or turn. And by doing it, you're torquing your elbow and wrist, which puts an unnatural force across the elbow at an early age. Again, we're talking about little leaguers or high schoolers, and these are the kids that not only are really good in their leagues, but they're being asked to pitch over and over by their either their parents or their coaches or their teammates. So there are now, um, phone apps developed where you can go on your smartphone and say, my son's 10 years old, he therefore should throw how many pitches this week? The answer 45. And should
Speaker 4:They be throwing sliders and curve balls at that
Speaker 5:Age? Not at all. Um, we tell people, teach your children to throw knuckle balls or a change up and uh, and those bring the ball into the pitcher or into the, into the batter much slower and it throws them off on their hitting. So that's what a curve, A curve usually comes in slower, but it moves. But a good knuckle ball moves up or down or side to side. So if you teach, um, young pitchers some off speed pitches without torquing the elbow, avoiding curves, avoiding the, the slider pitches, then those are more protective for the future for that, that pitcher's
Speaker 4:Arm. What is a pi what is a, a average pitch count for a, for a high schooler? Just, you
Speaker 5:Know, well, it can be a hundred pitches and I had a patient in my office who threw 142 pitches in his junior year, uh, in a game because the game went into extra innings and he was really good and his coach said, you're really good. And he kept him on the mound. He came to me, he had shoulder and elbow problems, and it's way too many pitches for anybody. Um, even in the pros, the a hundred number is pretty much where you see most pitchers taken out of a game per week. Per game
Speaker 4:Per game. Hundred
Speaker 5:Hundred game. Yeah, a hundred is a lot. And um, certainly when we talk about 45 in a week for a little leaguer, you can see, uh, you know, a high schooler throwing 140 pitches, you know, a travesty really, cuz it's way too much stress to the elbow and shoulder. And, uh, for that reason, um, we have to start much earlier in their careers in order for them to not have problems later. It's, it's estimated. And the numbers have varied obviously, that from that very first surgery in the seventies, almost one in seven professional baseball pitchers will have a Tommy John surgery in their career. Wow. And that's a lot of, a lot of people. And it's a, it's a big surgery and it involves quite a bit of
Speaker 4:Rehab. So before, last question, before we get into the details of the surgery, how do I know that I'm developing this, you said tingle in the fingers. Are there other things that maybe are earlier warning signs that maybe kids out there, parents of kids should be kind of looking at for
Speaker 5:Yeah, their, their elbows going to hurt. Okay. It's gonna hurt on the inside, which is the little finger side, not the thumb side of the elbow. And again, you're not gonna get that nerve symptom until the, the ligaments really stretched out a lot. So it doesn't mean you wouldn't get those. And there are people who have come to doctors in this state, and we're in Ohio who are nine years old and they've flown in from out of state to have Tommy John's surgery. And that's just, I think a little ridiculous. All right. So that means we're, what they're gonna complain mostly about is elbow pain, discomfort throwing and, um, difficulty getting back to where they were. And the only way to tell what's wrong is to do a good examination from a orthopedic surgeon. Uh, and the second way would be imaging with either an ultrasound or an mri. And there are partial tears. There are things where part of that, um, ropey structure called a ligament gets stretched and it's not cut. And in those cases, we talked earlier about platelet-rich plasma or prp, right? And there are times and there are articles showing, um, and these are some of the physicians who worked with the Dodgers back in the day who have shown putting, um, a well-placed PRP injection in a partially torn ligament can allow it to heal without surgery. It, it takes a while, but it actually tightens up the ligament and you can watch it. Ultrasounds allow us to move the body part dynamically and see if it wobbles open. We talked about what's called instability and that's the part that makes the elbow not just go up and down, but, uh, hinge outward like a, like a hinge on a door.
Speaker 4:So I, I, I apologize. I do have one more question about steroids. Can you inject steroids into your elbow to compensate for Tommy John injury?
Speaker 5:Uh, you should never do that because, uh, steroids or cortisone type medicines right, can weaken a tendon or a ligament and they are not a service to that ligament in any way. There are people who have what's called tennis elbow or bowlers elbow, some people have golfer's elbow. I tell people that's in a different pew in the same church<laugh>. So it's away from the ligament. And if you're putting a shot in those areas, actually PRP is probably better than a steroid injection on that also. But that's another, uh, discussion we've had. Um, but I think you, you can do cortisone away from the ligament, but you don't wanna use it to treat the ligament.
Speaker 4:Okay. So let's, let's go into what goes on in a Tommy John surgery. And by the way, have you, you've done these in the past,
Speaker 5:That's your I do not do this surgery. Okay. This is a very specialized surgery. Um, there are certain, uh, pockets of physicians who treat mostly high level athletes that do this surgery. This is a, a very extensive surgery. And since the ropey structure is stretched out, much like that rubber band holding your baseball cards isn't holding them, therefore you don't, you can't make that tighter. So they take a, a tendon in your wrist, uh, and sometimes you'll have to take it from the back of your knee called a hamstring and they'll, um, move it into a, be for simple terms, a figure of eight, weave through some little bone tunnels on the inside of your elbow and that recreates a new ligament. And it's much like that ACL surgery we talked about right in the knee where you put a tomato steak up the middle of the knee with a new graft. Is
Speaker 4:It an hour surgery, is it a three hour surgery?
Speaker 5:Well, it's certainly physician dependent. Okay. But I would say it's somewhere between one and two hours. And the most important part of the surgery is really the protection phase after. Okay. And the guided recovery program to where, um, I'd say the average non pitcher, let's say you're a shortstop, you might get back in a year playing, it's probably 12 to 18 months for most pitchers. Oh wow. For the recovery. But again, we talked about their velocity is gonna be, uh, pretty effective. Um, we also know that, you know, we talked about those pitch counts and when they look at the number of pitches kids do, we talked about little league. So if you're a nine to 14 year old and you threw over 400 pitches, you had a 65% chance of getting a Tommy John, uh, well a Tommy John ligament injured
Speaker 4:400 pitches over what period
Speaker 5:Of time? Um, over a, um, over a, I think it's over a week. And then if you were in the, uh, 400, 600 range, it would be, um, in the hundred 80% range that you may get an injury ligament. Yeah. And this may be, these may be, uh, a longer period of time, um, than a week period. I'd have to check that data cuz I have the, the number of pitches in the, uh, risk of tearing that, that UCL ligament we talked about. But it's, it's absolutely worse with what we call curve balls and sliders. The curve ball actually hurts more. The slider actually causes more injury to the ligament. So teaching the young children or the, um, developing pitchers, um, smarter ways to pitch and limiting their pitching is the key to preventing this from being a problem later. So that's, and again, if they're, if they're playing all the way through little league, high school, college and now you somehow make it to, you know, minor league, major league baseball, that arm's been through a lot of pitches.
Speaker 4:Yeah. Okay. So prevention is just basically reducing the amount of pitching per week or per time cycle that we, we, we talked about. Uh, is there anything else we can do to help prevent it? Is there, are there things that we could, could be doing to offset, if I'm pitching a lot, I can go back and soak it in ice or something to help, you
Speaker 5:Know? Well, we always talk about rice, which is rest, ice elevation and um, some type of, um, compression, like a little sleeve on it. Right? But, but the best thing I tell baseball players is don't play baseball year round. You know, go play soccer, go play some basketball, use other parts of your body. These kids are on travel teams, then they're on their school teams, then they're on another fall travel team and it's year round abuse really to their body parts. And the best thing and the best athletes frequently are multi-sport athletes or people that give their body a chance to rest and recover between seasons. So not just, you know, what do you do when it happens? I think you need a diagnosis. We talked about that. And anything in medicine you have to know do I have a, do I have any injury at all to that ligament? Do I have a partial tear or could it be completely joint? Can you,
Speaker 4:How do you tell if I have an injury?
Speaker 5:Well, if I'm examining you, uh, you're just like, we check a knee ligament, it may hinge open toward, you know, it may, by putting stress across the joint, uh, using an examination, um, the doctor can see if that that ligament feels, uh, looser Okay. Than the other side. You can check the other arm. The other thing we have is ultrasound, which can show us if that ligament is stretching. And then the, you know, best, the best details are always with an mri. MRIs give us um, very um, excellent details of soft tissue injuries. This is not a bone, so this is a ropey ligament we talked about and therefore we can see is this stretch long wise or is it cut like directly transversely through the ligament? If it is cut transversely and the person wants to pitch again, they pretty much need to have it repaired. Okay. Now I have a injury to my ligament, but it happened when I was pitching in my forties. And so as I got older, my arm got a little stiffer and it wasn't really wobbly and I never got mine fixed. You know, I had a little bit of gravel in my elbow. Um, I didn't need to have a big reconstruction. This is a big surgery. And um, how I told people the Cincinnati Reds did not need me pitching in my early forties for their, uh, team that year.
Speaker 4:So when you said it's a big surgery, it sounded when the procedure itself didn't sound that complex or that didn't take that long, you're in and out, you're an inpatient outpatient kind of thing. Right.
Speaker 5:Well just cuz the surgery is an in and out surgery doesn't mean it's not a complex surgery. Okay. So an ACL surgery is a big reconstruction of your knee and someone needs to put the little bone tunnels where the ligament goes in the right place or the knee doesn't, doesn't work. Right. Okay. Same thing with this elbow surgery. That's why a lot of doctors don't do this surgery. In fact, probably over 90% of orthopedic surgeons do not do Tommy John's surgery. So, and, and ironically, um, in the world of sports medicine at this elite level, believe it or not, the people who guide most of the direction of where someone goes for these surgeries are the agents. So when you're, when you're like Jerry McGuire and you gotta 20 million pitching arm there and you're getting 10% of that guy's salary, and I'm sending you to the Wizard of Oz<laugh> because he's the best guy or girl who can do that surgery because he's done five other people on your, um, roster of players and, you know, he gets people back with a great outcome or
Speaker 4:All right, so let's, let's spend a little time as we wind us down, uh, to talk about what can they expect. So if I have this done and I'm sitting out for 18 months to two years, which seems like a long time for an athlete, uh, can they expect this new ligament to be good as new and they're not gonna see any issues with it and it'll last for a long time? Or is this something they gotta baby?
Speaker 5:Right. Most people never need this done again. However, there are plenty of examples of people who have had two Tommy John surgeries. They've had to take a ligament from the other arm to re make another ropey, you know, stabilizer for the elbow. Um, and then there are times where people never get their velocity completely back. And again, um, it depends, you know, was there any injury to the nerve? Was the, um, are there some things that caused burning or tingling where that nerve had been stretched a little more than it than than it should have? Um, so, uh, the textbook answer is the people that go through the surgery are pretty happy. They get their velocity back, the numbers prove they do. And they, if they were throwing 94 miles an hour, they're gonna throw 94 miles an hour after their recovery time. And what's he, that's what makes the coaches and the, and the owners and the agents happy. Absolutely. And ultimately the player because he's doing the rehab.
Speaker 4:So what is the age that you should have a Tommy John surgery?
Speaker 5:Well, great question. I think that's a question for the people that do the surgery, but I would say, I know it's being done in adolescent years. Wow. Probably late teens. That's earlier. And then there were, as I said, there were parents and maybe coaches encouraging kids at younger ages because they had that injury and that means they had overdone something at a much earlier age. Um, the funny thing about the, um, the surgery is that, um, they interviewed Frank job on ESPN and they asked him about the surgery and they said, Hey, is this really more than you dreamed it ever be? And he said, it is, but I probably would've called it Sandy Cofaq Surgery<laugh>, um, if I had thought of it 10 years earlier,<laugh>. And they said, well, well why is that? He said, well, Sandy Kofax had the same problem that Tommy John had 10 years earlier. I just didn't have an answer or had not come up with this procedure to fix it, or it would've been called Sandy Kofax surgery.
Speaker 4:All right. So this has been a kind of a fascinating one for us cuz it, it combined sports as well as some, uh, medical information for the listener. Have I left off any question I should have asked?
Speaker 5:No, I think it's, um, I think it's, as you said, it's a really important topic to show where prevention is really important and some of the newer technologies we have, you know, smartphone apps to track pitch counts, modifying, um, younger pitchers, um, arc of mo of movement and type of pitches. And, and again, I think it's pretty much exclusive to baseball. Uh, the underhand softball throwing is more of a, uh, a fluid motion. Uh, there's probably some, uh, involvement but much less, more than overhand throwing. Right. So I think it's, I think it's well worth trying to get ahold of this problem at a much earlier age, but I think we are seeing all the effects of not doing that in the people that are older now who are having the surgery. Okay.
Speaker 4:Well, Dr. John US has been a fantastic podcast here and hopefully the people are gonna enjoy listening to this topic. And if you're a baseball player, I know you will and, uh, we'll see you here again pretty soon. I think we're gonna do one on robotic knee surgery coming up soon, is that correct?
Speaker 5:It'll be, uh, yep. The use of, uh, robotics in, uh, total hip and total knee surgery. That'll be our next podcast. And, uh, all these will be listed on dr john ers.com so feel free to float around the website, leave a review, or some suggestions for future topics.
Speaker 4:All right. Thank you all very much for joining us today on the Bone and Joint Playbook with Dr. John ERs, Ontario O'Brien. I'll see you soon. Bone,
Speaker 6:Thank you for joining us today on this episode of The Bone Enjoying Playbook with Dr. John Earth, tips for pain-free aging. Please join us again for another episode. This has been a production of Doctors Unasked, produced by Terry O'Brien.