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In the Treatment Room: A Discussion About Tommy John Surgery

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Earlier this Spring Dekoda Watson underwent Tommy John Surgery and has spent most of the spring watching from the sidelines. No...Dekoda was not out trying to make it onto an MLB club.

In the installment of the "In the Treatment Room Series," we take a look at what has become one of the most famous medical procedures in sports these days.

Photo from here.

If you search for "Tommy John Surgery" in Google, you will be provided with 375,000 results. The most common sport with which the procedure is associated is baseball. In fact, that is how the procedure earned its name. Tommy John was a pitcher for Los Angeles Dodgers and tallied 288 wins in a career that spanned 26 years. He played for the Indians and White Sox before landing with the Dodgers in 1972. After starting the season 13-3 in 1974, Tommy damaged his Ulnar Collateral Ligament (UCL) and was operated on by Dr. Frank Jobe on September 25th, 1974. Apparently, Tommy told Dr. Jobe to "make something up" to fix his elbow.  Tommy took the 1975 season off and returned with a 10-10 effort in 1976. Here are Tommy John's stats from Baseball Prospecus.

To understand the Tommy John Surgery, we first need to take a look at the anatomy of the elbow. The elbow essentially functions as a hinge joint, allowing you bend and straighten your arm, but there is also rotation occurs at the elbow (twisting your forearm). Here is an image that demonstrates how your humerus (upper arm) and radius and ulna (the two bones in your forearm) come together to form your elbow joint:

Image from here.

Looking these images can be confusing. The one on the top shows a front view of the elbow. The radius is the bone that runs down the thumb side of your hand and the ulna runs down the little finger side. Figure B is looking at the elbow from lateral side, meaning from in the outer portion and image C is looking at the medial side of the elbow.As you can see, there are lots of ligaments that hold the elbow together. (Remember that ligaments connect bones together and tendons connect muscle to bone.)

Things get even more confusing once you include all of the muscle, arteries, nerves and veins that run across the elbow, as shown here:

Image from here.

The important thing to take from the two images is the location of the ulnar collateral ligament shown in the top image. The Ulnar Collateral Ligament (UCL) is the primary medial stabilizer of the flexed elbow joint, meaning that when your elbow is bent it provides the stability to the joint along the inner portion of your elbow. There are three major parts of the ligament: anterior, posterior and transverse. If you were to cut the anterior part, your elbow would be totally unstable except when it was totally straight.

Damage to the ligament typically occurs during throwing motions, particularly in baseball and occurs when your arm is bent about 30 degrees. This obviously happens during a throwing motion. At that point, the other structures in the elbow provide little support to the joint, meaning a significant amount of the load/weight/force is placed on the UCL. This typically occurs during the acceleration phase of an overhead throw, so as the pitcher is moving toward the plate as the forearm lags behind the upper portion of the arm. This leads to chronic microscopic tears leading to inflmation, pain, weakness or even acute rupture or tear of the ligament.  Pitchers may report pain during their throw and even sometimes they will feel a pop as the ligament ruptures. If they have inflammation, it gets better with rest and worse with throwing. So how did this happen to Dekoda? You can damage the elbow during a fall with an outstreched arm that may result in elbow dislocation.

Watson injured his elbow prior to the VTech game. Here is an image of him wearing that huge brace he had on for the remainder of the season:

COLLEGE PARK, MD - NOVEMBER 22:  Myron Rolle #3 and Dekoda Watson #36 of the Florida State Seminoles defend against the Maryland Terrapins on November 22, 2008 at Byrd Stadium in College Park, Maryland.

Image from here.

Diagnosis of the injury is primarily on history and physical exam. X-rays and other imaging studies can help. For example, you might see a tiny fracture in the bone where the ligament has been pulled away from the bone, there might be an increase gap in the space between the bones seen on x-ray. MRI is now becoming the imaging of choice to help in the diagnosis. Some will argue that going to surgery and taking a look inside the joint is the best because you can manipulate the arm and see exactly what is happening to the joint as you watch inside the joint. However, clinical suspicion and a good exam are usually sufficient.

The way they surgically correct the damaged ligament is to replace it with a tendon somewhere else in the body. Here is an outstanding image of how they repair it:

Image from here.

There are some muscles in your body that really don't contribute much to anything and they will harvest the tendon to replace the ligament. (Notice the wording) The surgeons go in and drill through the bone and insert the new tendon in the figure-8 pattern described above and this reinforces the joint, essentially replacing the damaged ligament. If you want a really detailed explanation you can go to the Baseball Prospectus for a complete explanation.

Here is a nice video about the procedure. If you have a light stomach, don't watch it as there are some images from surgery.

This procedure is occurring more and more frequently but has a good success rate. Some studies quote that 83% of individuals return to their previous level of competition. Of major league pitchers, 75% are able to return. The average time of recovery is about 1 year. Although this surgery may be most common in baseball players, it does not occur exclusively in baseball players. About 5% of individuals having the Tommy John procedure are not baseball players, typically football or track (specifically throwers). I don't know when Dekoda's expected return to the playing field will be. Obciously, this is different than a pitcher as he does not need full return of function to be able to play the linebacker position and he was able to play a significant ammount of time last year with the brace.

As always, I encourage feedback and questions. Hope this helps you guys understand Tommy John Surgery a little better.