Pitcher’s Elbow – Dr. Elliot Robinson

Hand & Upper Extremity Sports Medicine | October 19, 2021

There are several pathologies other than ulnar collateral ligament tear the elbow surgeon sees in throwing athletes

Baseball is America’s pastime with a strong tradition in Georgia. However, no other sport places the athlete’s elbow at more risk. This has been magnified as athletes specialize earlier, throw harder, play year-round, and in general, “put more miles on their elbow” at a young age. Unfortunately, a broad range of elbow injuries in the throwing athlete can have career-ending implications if not addressed in a timely fashion. 

In 1974, major league pitcher, Tommy John, tore the medial ulnar collateral ligament, the supporting ligament on the inside of his elbow, which was thought to be a career-ending injury. He sought the care of orthopedic surgeon Frank Jobe who came up with an untested, but promising, technique to restore stability to Tommy’s elbow. He borrowed a tendon from Tommy’s forearm to reconstruct the medial collateral ligament. Tommy made an unprecedented recovery and went on to win 164 games for the Dodgers and Yankees after his surgery. The procedure was named after Tommy John and variations have been used to save countless throwing careers.  

There are several pathologies other than ulnar collateral ligament tear the elbow surgeon sees in throwing athletes which are due to “valgus extension overload” mechanics. This refers to the torque placed on the elbow as energy generated in the legs and trunk is transmitted to the ball with the elbow acting as fulcrum.  Tremendous tension is placed on the inside structures of the elbow which can lead to tearing of the ulnar collateral ligament. In a young athlete, however, the growth plate on the inside of the elbow is weaker than the ligament. Instead of a ligament tear, the bone can be pulled apart little by little or as an acute break. These injuries need rest, casting, or surgery depending on the severity. Another tension problem is ulnar nerve irritation, which presents as elbow pain, little finger numbness, and sometimes hand weakness.  

When there is tension on one side, there is compression on the other. This is particularly important in growing athletes. The immature skeleton is relatively soft and susceptible to repeated microtrauma. Excess compression on the capitellum on the outside of the elbow can weaken it, leading to osteochondritis dissecans. In the same way a pothole develops from loose gravel on the road surface, the bones supporting the joint cartilage soften. X-rays in the early stage are frequently negative, but if the lesion is not able to heal, a “pothole” develops. The resulting loose bodies get stuck in the joint, leading to painful catching and decreased range of motion. This can often be treated with arthroscopy to remove the fragment and clean up the defect. On occasion, a cartilage and bone plug is harvested from the knee to fill the defect.

The Tommy John’s story is a great example of will and skill overcoming a difficult situation. Perhaps knowing there is a fix gives athletes and coaches excess confidence. In fact, there is an ever-increasing rate of Tommy John surgery being performed. According to one survey, one in nine major league pitchers undergoes this surgery. Additionally, while the surgery used to be performed almost exclusively in mature professional pitchers, the majority of are now done on college and late teenage athletes. The downsides are Tommy John surgery offers no guarantee of successful return to competition and the rehabilitation process is an arduous year-plus process.

Clearly, prevention of elbow injuries deserves at least as much publicity as Frank Jobe’s ingenuity and Tommy John’s remarkable recovery.

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