The Cost of Throwing 100!

The Los Angeles Angels recently announced that their star player, Shohei Ohtani, would not pitch anymore this season due to a tear in his right ulnar collateral ligament (espn.com). Ohtani, arguably the greatest baseball player of this generation, may need Tommy John surgery, which would be the second time in his career that he would need that kind of surgery. According to an article in USA Today (Lacques, 8/31/23), the number of players able to throw 100 mph is increasing, but so are the number of pitchers needing Tommy John surgery.

Tommy John surgery, aka ulnar collateral ligament (UCL) reconstruction, is a procedure that uses your own tendon or a donor tendon to replace the torn UCL (John Hopkins Medicine). The surgery is commonly named after the first professional baseball pitcher to undergo UCL reconstruction, Tommy John. Dr Frank Jobe, the Dodgers team doctor at the time, performed the revolutionary surgery on September 25, 1974 (Wikipedia).

The ulnar collateral ligament is a strong band of tissue on the inner side of the elbow. The elbow is a joint where the upper arm (humerus) meets the two lower arm bones (ulna and radius). This ligament helps stabilize the elbow in movements like throwing. As the name implies, the UCL is on the ulnar side of the joint. The UCL is made of 3 bands: a front (anterior) band, a back (posterior) band, and a diagonal (transverse) band.

Symptoms of a UCL tear include pain on arm movement, weak feeling at your elbow or grip, and loss of velocity when throwing. Tears are graded in 3 stages (Cleveland Clinic.org):

Stage 1 – ligament stretched, but no tear

Stage 2 - ligament stretched, and possible partial tear

Stage 3 - ligament completely torn

Figure from https://rileywilliamsmd.com/ucl-mcl-injury-orthopedic-elbow-specialist-manhattan-new-york-city-ny/

The 2 most common causes of a UCL tear are overuse and trauma. Tears are diagnosed usually with CT scans or MRI/MRAs. Doctors can also perform the valgus stress test in office where they put fingers on the UCL and push the elbow inward and upper arm outward. A positive test is when there is looseness of the elbow joint and pain.

UCL stretching or minor tears may heal on its own or with conservative measures like rest, ice and physical therapy. Injections of platelet rich plasma (PRP) may also assist in healing. If the damage and pain are significant enough, most baseball players will opt for Tommy John surgery. The most commonly used tendons to replace the torn UCL are taken from the hamstring, big toe or forearm. The tendons are reattached to the elbow using various surgical techniques. On average, the player will need 9 months to 1 year of recovery and rehabilitation to return to competition.