Tommy John Surgery (Ulnar Collateral Ligament Reconstruction)

• The ulnar collateral ligament (UCL) is the major stabilizer of the elbow.
• UCL injury is an overuse injury, most often caused by the repetitive motion of throwing.
• Symptoms include pain over the medial part of the elbow that worsens with throwing and gets better with rest.
• Usually, health care professionals diagnose UCL injuries by history and physical exam and confirm their diagnosis by MR arthrogram.
• Tommy John surgery is named after the Los Angeles Dodgers pitcher who was the first to undergo UCL ligament reconstruction.
• The surgery does not repair the ligament but instead replaces it with a graft.
• Rehabilitation after Tommy John surgery takes months, and the goal is to return the player to competitive throwing within a year.

Dr. Frank Jobe first performed surgery to graft and repair the ulnar collateral ligament in the elbow on Los Angeles Dodgers pitcher Tommy John in 1974. After a year of rehabilitation, John returned to pitching in the Major Leagues and won more games after his surgery than beforehand.

The UCL injury had been career ending for pitchers at all levels of competition, but after the success Dr. Jobe's operation, the procedure's use was refined and is now commonly performed.

The ulnar collateral ligament is the major stabilizer of the elbow. Damage to the ligament is due to overuse, most often because of throwing and is often associated with baseball pitching and other throwing sports. The ligament may fray, tear, or gradually become loose, causing the elbow to become painful and unstable.

On occasion, a fall on an outstretched hand can tear the UCL in the elbow.

Symptoms of UCL injury tend to be chronic, presenting with medial elbow pain, especially with an overhead throwing motion. Pain tends to get better with rest but recurs with activity. The pain causes decreased throwing ability and decreased velocity or speed.

Physicians suspect UCL injury based on history and physical exam.

There will be tenderness, with or without swelling, along the inside part of the elbow just above the epicondyle, where the UCL inserts. When the joint is stretched, pain may be worse. Pain increases when the patient clenches a fist.

Imaging

• Plain X-ray may be useful in looking for bony injuries that can mimic UCL tears, including avulsion fractures, where the ligament pulls away a piece of bone.
• Ultrasound may assess the ulnar collateral ligament looking for a tear.
• MR arthrography is often the test of choice to assess the ligament and any other abnormalities in the elbow joint. A health care professional injects dye into the joint and then performs an MRI. It can determine both partial and complete tears of the UCL.

An orthopedic surgeon may perform arthroscopy to directly evaluate the UCL and the elbow joint.

Though a variety of doctors, from primary care providers to sports medicine specialists, may make the diagnosis of UCL instability or tear, the diagnosis and treatment usually requires consultation with an orthopedic doctor who usually specializes in sports and upper extremity injuries.

Health care professionals usually recommend surgery for competitive athletes who want to return to play, if there is chronic instability of the elbow joint, or if chronic pain persists. Often, health care professionals only recommend surgery after conservative treatment with physical therapy has failed.

Tommy John surgery does not repair the ulnar collateral ligament but instead replaces it with a graft from another ligament in the body or from a cadaver donor. Many times, physicians relocate the ulnar nerve that runs nearby to prevent its inflammation.

Recovery after surgery requires patience. The goal is to be able to return to throwing at a competitive level within a year.

The following is an example of a rehabilitation program. Doctors will individualize the specific regimen for the patient's specific situation:

• 0-2 weeks: elbow is kept in a splint
• 0-4 weeks: hinged brace is sued to promote gradual increase in range of motion
• 4-8 weeks: isometric exercises for strengthening
• 8 weeks-plus: increased strengthening exercises
• 12weeks-plus: plyometric exercises
• 4-6 months: throwing exercises
• 9-12 months: return to competition