STRIKE!

Looking behind the baseball at UCL injuries … and the role former Los Angeles Dodgers pitcher Tommy John plays

 

The goal of every great baseball pitcher is to strike out the batter.  To do this requires not only talent but extreme power every…single…pitch.

Few other athletes are required to throw with this kind of power as frequently as a pitcher.

Over the course of a baseball career, particularly if begun at a young age and played competitively, this high speed force repeatedly placed on the elbow can take a toll.

Often beginning with Little Leaguer’s Elbow, a condition affecting young pitchers who do not allow adequate rest between pitches, a baseball player’s elbow joint absorbs a tremendous amount of repetitive stress over the seasons.  The impact of this type of overhead throwing irritates the tendons and ligaments supporting the elbow joint, predisposing pitchers to more serious problems.  One such injury is an Ulnar Collateral Ligament (UCL) injury.

Once seen primarily in adult athletes, the dramatic increase in more serious overuse injuries like UCL damage, Flexor Tendinitis and Valgus Extension Overload (VEO) in young players prompted the American Sports Medicine Institute (ASMI) and the USA Baseball, Little League Baseball and Major League Baseball organizations to establish Pitch Count Guidelines.

While these changes and educational efforts are expected to reduce the number of overuse injuries seen in young players, competitive league players remain at risk.

Ulnar Collateral Ligament (UCL) Injury

Elbow Anatomy and UCL Injury

The Elbow Joint and location of the Ulnar Collateral Ligament

The ulnar collateral ligament (UCL) is among the most commonly injured ligament in throwing athletes.  To accommodate the high speed throwing motions, the ligament stretches and lengthens until it can no longer hold the elbow bones tightly enough. Severity of the injury can range from a sprain with minor damage and inflammation to a complete tear.

Symptoms Include:

baseball bullet

Pain on the inside of the elbow

baseball bulletA feeling of instability in the elbow

baseball bulletLoss of strength in throwing

baseball bulletIrritation of the ulnar nerve (funny bone) causing numbness in the small and ring fingers

Diagnosis and Treatment

A UCL injury is diagnosed based on the results of a physical examination, X-ray and MRI.  Depending on the severity of the damage, rest and refrain from play along with rehabilitative exercises and anti inflammatory medication may be indicated. Work with an athletic trainer may also be helpful, to assess throwing mechanics and improve body positioning which can reduce excessive stress on the elbow.

If there is a complete tear of the ligament and patients fail to improve with conservative treatment, surgery may be indicated.

The UCL reconstruction procedure, which was performed on former Los Angeles Dodgers pitcher Tommy John and is more commonly known as Tommy John surgery today, has dramatically changed the outcome for athletes.  In fact, his results were so impressive, it is reported that young players not actually suffering from a UCL injury have sought Tommy John surgery in hope that it would improve their performance [1]!  The procedure, though, is performed only when necessary to repair a severely torn UCL.

Tommy John surgery is a surgical graft procedure in which the injured UCL is replaced with a tendon graft taken from the forearm or the hamstring tendons.  This procedure is followed by an intense rehabilitation program that lasts from six months to a year, depending on the position an athlete plays.  Throwing exercises can begin in about 16 weeks.

The Role Tommy John Continues to Play

In the medical community, Tommy John remains credited with the shift in how athletes view UCL injuries. Once career ending, today UCL reconstruction has become a common procedure – returning most athletes to their sport at a pre injury level of play.

In the sports world, Tommy John is still revered for the excellent athlete he was, choosing baseball as his sport of choice and playing in all three of the Yankees vs Dodgers World Series in his era (1977, 1978 and 1981).

Undergoing the procedure in 1974 and spending his entire 1975 season in recovery, he learned to pitch in a way that relieved the stress he was placing on his arm and leg.  He returned to the Dodgers in 1976. His 10-10 record that year was considered “miraculous.”  But, he went on to pitch until 1989 winning 164 games after his surgery – just one game shy of baseball great Sandy Koufax.

The recognition he received for his unexpected success following the procedure now donning his name became the launching pad for other endeavors benefiting young baseball players.

His “Let’s Do It” foundation, which umbrellas the Tommy John Pitching Academy, is today dedicated to research in preventing such injuries and teaching pitching techniques that minimize the physical impact. The foundation also supports the efforts of the American Orthopedic Society for Sports Medicine (AOSSM) and its collaborators’ STOP Sports Injuries Campaign as well as the American Foundation of Suicide Prevention (AFSP).  AFSP and its outreach effort is an important component in the foundation’s efforts in memory of his son.

 References

  1. Longman, Jere. Fit young pitchers see elbow repair as cure-all. 2007 Jul.

 

 

Track and Field Hand & Upper Extremity Injuries and Conditions

As track season sprints past, we begin to see some common overuse injuries and conditions in these athletes.  While the vast majority of those seen in track and field affect the lower body, there are several common hand and upper extremity injuries and conditions seen in throwing events such as the javelin, shot put, hammer and discus.

Between weekly practices and weekend competitions, overuse injuries and conditions in throwing events account for most upper extremity injuries in track and field. These overuse conditions often affect the rotator cuff and shoulder labrum. Overuse conditions are those resulting from the repetitive use of a particular limb/joint(s) and are frequently seen in baseball, swim and tennis as well.

Other track and field injuries include ulnar collateral ligament (UCL) tears of the elbow (also known as a Tommy John injury) and thumb.  Also metacarpal (hand) fractures are seen resulting from repeated stress on the small bones of the hand.

Rotator Cuff Injury

There are four tendons and muscles that make up what is known as the “rotator cuff,” providing coverage around the shoulder joint at the top of the humerus. The rotator cuff holds the arm in place and allows it to move with the broad range of motion we demand not only in everyday activity but also in many throwing sports. This broad range of motion, though, predisposes the shoulder to injury.  Repetitive stress on the rotator cuff can cause partial tears and swelling in the tendons.  A “high impact” stress, such as the powerful force required in these track and field throwing events, may cause one of the tendons to pull away from the bone or tear.rotator cuff injuries cropped

Rotator Cuff Injury Symptoms and Diagnosis

While most rotator cuff injuries can be slow to develop – producing nagging pain in the shoulder and arm, shoulder weakness and difficulty lifting the arm overhead – sometimes they can be quite sudden. In this case, athletes may feel a “pop,” followed by strong pain and a weakened arm.  An orthopedic specialist will assess the injury initially with a physical examination and review of the activity leading up to the injury.  This may be followed by a shoulder x-ray, MRI and/or arthrogram.  Treatment depends on the severity of the condition and will include a period of rehabilitation therapy. Conservative, nonsurgical treatment is often considered initially.  Surgery may be indicated if shoulder instability persists or there is a complete rotator cuff tear.

Shoulder Labrum Tear 

Another common track and field throwing injury is a shoulder labrum injury.  Among the most commonly diagnosed shoulder labrum condition in athletes involved in throwing sports is known as a SLAP (superior labrum, anterior to posterior) tear. The labrum works to keep the arm bone in the shoulder socket. When the ring of firm tissue that helps to make the shoulder more stable becomes stressed, it can result in a SLAP tear, compromising shoulder stability.    Often damage to the labrum occurs in those athletes who are also suffering from rotator cuff injury or weakness.slap-tear-1

SLAP Tear Symptoms and Diagnosis

Some of the common symptoms associated with SLAP disorders include a popping, clicking or catching in the shoulder during throwing activity, aching pain and feeling of weakness.  Beyond a physical examination, a diagnosis may include an MRI and/or an arthrogram.  Occasionally minimally invasive arthroscopy may be used to confirm a tear.  If a tear is confirmed, the surgeon may choose to repair it at the same time.

UCL (Ulnar Collateral Ligament) Injury

Ulnar Collateral Ligament (UCL) injuries of the elbow frequently occur in javelin as a result of the throwing motion and stress on the elbow.  Also known as a Tommy John injury, it is similar to the stress placed on the elbow in baseball.

The elbow is basically a “hinge” joint allowing not only bending and straightening but also rotation from palm up to palm down.  Several important ligaments in the elbow joint facilitate this range of motion, connecting the bones (ulna, radius, humerus) and forming part of a lubricating joint capsule.UCL of elbow

Two of the key ligaments for elbow joint stability  include the lateral collateral ligament and the UCL, which is also known as the medial collateral ligament because of its location on the elbow (inside).

When overuse of the joint (force on the soft tissue exceeds that of the structure’s tensile strength), such as in a throwing sport like javelin, places stress on the UCL, tears can develop.  The ligament stretches and lengthens to the point that it can no longer hold the bones tightly enough during throwing activities.

UCL Injury Symptoms and Diagnosis

Athletes suffering from this type of overuse condition may experience pain along the inside of the elbow, which is worse during the “acceleration phase” of throwing.  There may also be swelling, reduced range of motion and feeling of instability in the elbow.  Throwers may also have tingling or numbness in the “pinky” and ring fingers and experience difficulty throwing.

Diagnosis includes a physical examination, x-ray and an MRI.  Treatment is initially conservative and may include rest, ice and anti-inflammatory medications, along with physical therapy to strengthen surrounding muscles and compensate for the injured UCL.  Following this, or in more severe cases, a UCL reconstruction may be indicated. Also known as Tommy John surgery (named for the Los Angeles Dodgers’ pitcher who first underwent the surgery), the procedure entails taking a tendon from another area of the patient’s body and replacing the injured UCL with it.

Metacarpal (Hand) Fracture

While less common than overuse injuries and conditions, hand fractures can result from the repetitive stress and force placed on the small bones of the hand.

With a total of 27 bones in the hand (14 phalanges, five metacarpal, eight carpal), more than half of the bones making up the entire upper extremity,metacarpals fractures are inevitable in sports placing extreme and repeated stress on the hands.

One such fracture is known as a metacarpal fracture, which affects the bone at the base of the finger closest to the wrist.

Metacarpal Fracture Symptoms and Diagnosis

Metacarpal fractures will cause immediate pain and possibly visible deformity. The injured finger(s) may swell, and there may be some bruising.

A physical examination and an x-ray Metacarpal hand fracture repairwill identify the location and severity of the fracture.  Treatment is determined based on whether the fracture is “stable” or “unstable” and the extent of injury.  More severe cases may require surgery and internal fixation (K-wires or plates and screws), followed by a period of splinting and hand therapy.

Prevention and Treatment

Understanding that adequate rest between practices and events is as important as the training will help reduce the likelihood that an overuse condition will result in a tear or stress fracture. Maintaining balanced strength and conditioning of opposing muscle groups is also an important prevention component.

When symptoms are addressed early, the injury often responds well to conservative treatment.