Torn UCL: Not Just a Major Leaguer’s Problem

From the WebMD Archives

Tom Borak had just completed the best summer of baseball he could remember. It was a weekly men’s league in 2007, a triumphant return to the game he loved following a four-year layoff during college.

His fastball was popping in the low 90s. He had good control of his curveball. And his teammates had convinced him that he should attend an open tryout with the Atlanta Braves. To get ready for that -- and the upcoming fall season -- he threw a couple of times a week. During one of these workouts, he felt a pop in the elbow of his right arm. It was the sound of his future taking a sharp turn.

“I knew something wasn’t right but tried to ignore it,” says Borak, 33, communications and membership manager for the Colorado BioScience Association in Denver.

He made his first start of the fall season on a chilly September morning, and his arm felt exhausted from the start.

“Each inning it got progressively worse,” he says. “After the third inning I couldn’t lift my arm over my head to take my shirt off. That’s when I knew it was serious.”

A Major Shift in Treatment

Turns out, that pop in his elbow had thrust Borak into a large and growing group of athletes. It was a partial tear of his ulnar collateral ligament (UCL). It comes from that constant throwing action -- doctors call it a repetitive motion injury -- and it has plagued pitchers for more than a century.

People used to call it a “dead arm” because it meant a dead baseball career. But the odds for pitchers took a huge jump in 1974 when surgeon Frank Jobe rebuilt Los Angeles Dodgers hurler Tommy John’s left elbow. Jobe’s life-changing procedure saved John’s career. He pitched 14 more seasons in the majors.

In the years since, Tommy John surgery, as it’s now known, has become common. That’s because it works so well. And that’s a good thing, because there are more UCL injuries than ever before reported in the major leagues.

Throwing a pitch calls for a great deal of twisting on the inner part of the elbow. It requires more strength than the ligament has, says E. Edward Khalfayan, MD, orthopedic surgeon for both the Seattle Mariners of Major League Baseball and the NFL’s Seattle Seahawks. “It’s amazing we don’t see more of these injuries.”

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It Can Happen to Almost Any Athlete

Khalfayan has treated pro football players, golfers, and javelin throwers with UCL injuries. Across the country at Johns Hopkins University, orthopedic surgeon Andrew Cosgarea, MD, has treated tendon and ligament tears in tennis and volleyball players, wrestlers, at least one ultimate fighter, and the occasional softball player.

“Usually it’s someone from a summer beer league, typically an outfielder who has made one too many hard throws and feels that painful pop in his elbow,” says Cosgarea, who leads the division of sports medicine at Johns Hopkins.

But most of these injuries are associated with baseball. Outside of pro ball, most of Khalfayan’s patients are teenaged pitchers. “Kids in youth baseball, high school, and college ball,” he says.

With youth baseball now going virtually year-round, it’s no wonder there’s a rise in overuse injuries like a torn UCL. Kids who throw hard year-round without enough rest often wind up in the operating room.

No Guarantees

At the same time, some people believe that Tommy John surgery means a pitcher will come back stronger than ever.

Cosgarea says, “Techniques have improved over the past few decades, but it’s still a challenging operation requiring a substantial amount of skill and experience."

He estimates that operations to rebuild a torn ACL in the knee outnumber UCL operations “by 10 to 1 or 20 to 1, depending on the kind of practice you have. If you take care of a baseball team, you’re going to do more UCLs.”

It Isn't for Everyone

Cosgarea doesn’t suggest Tommy John surgery to every patient with a torn UCL.

“Many people can tolerate a torn or stressed UCL for the rest of their lives,” he says. “There aren’t many activities that require that kind of stress, over and over again, on that inner part of the elbow.”

Khalfayan doesn’t even see it as an option for every pro athlete he treats. Seahawks defensive back Richard Sherman is an example. His job doesn’t require him to throw 90 mph fastballs.

For pro athletes and weekend warriors alike, treatment for most elbow-related throwing injuries begins with rest. And unless you’re a pitcher or a shortstop or someone else who needs a hammer for an arm, you probably won’t need a retooled UCL.

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New Life for a Dead Arm

Borak felt he did need it. He was in his mid-20s, at the tail end of his window for joining pro ball. After his awful fall season start, he rested his arm for 2 weeks and then went to the Braves tryout in Richmond, VA.

“My curveball was at 82 miles an hour, my fastball was 84, a huge drop,” Borak says. His doctor prescribed rest and therapy. Instead, he spent 6 months in the gym to build his arm strength.

The next season, his arm was still dead. He couldn’t even make a throw from the outfield. But he still wanted to play in the big leagues, even if it was just for the fun of it.

Gordon Singer, MD, a Denver orthopedic surgeon, performed Borak’s surgery on Halloween 2008.

Fast Fix, Slow Return

If, like Borak, you decide to have Tommy John surgery, your doctor will replace the torn ligament with tissue either from somewhere else in your body or from a donor. Doctors like to use the palmaris tendon in the forearm, but not everyone has one. Other choices include your hamstring (the big muscle on the back of your thigh) or your foot. Donated tissue comes from a certified tissue bank.

The surgeon drills holes in the bones on either side of your elbow and attaches the graft to the bone to replace the torn ligament. The repair is a quick fix -- you’ll have outpatient surgery and go home the same day. But the road back is longer.

A Recovery Timeline

Unlike a pro, who'd have major league rehab experts and tools at his fingertips, Borak created his rehab regimen through Internet research. It involved a lot of work on his shoulder.

The shoulder allows you to speed up and slow down your arm, he says. ”The elbow is the rubber band on a slingshot. You need a strong base for the rubber band to be strung,” says Borak, who increased his pitching speed because his shoulder got so strong.

If you have UCL surgery, the rehab process starts a week after the operation. You’ll go home wearing a long splint and trade that for a brace when you go back to the doctor.

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After surgery, a physical therapist will manage your care. How often you see him depends on your specific needs. A typical schedule might be:

  • One to two times a week for the first 6 weeks
  • Two to three times per week for weeks 7-16
  • One to two times per week from week 16 to return to full activity

Everyone is different, but in general here’s what you can expect:

Weeks 1 to 2: You’ll focus on keeping your pain under control. You’ll add some light exercises to work on your grip and range of motion. You’ll keep your brace locked at a 90-degree angle unless you’re exercising.

Weeks 3 to 6: You’ll keep working on range of motion and add resistance exercises. You’ll begin work to strengthen your shoulder. You can ditch the brace except when you’re outside or asleep. You can walk or ride a stationary bike for cardio, but don’t run, and stay off the treadmill.

Weeks 7 to 14: You should get your full range of motion back and build strength in your entire arm.

Weeks 15 to 24: You can begin light sporting activities. Your therapist may also start you on a structured throwing program. You may also need to work on other parts of your body, like your hips, to make sure your throwing motion doesn’t add stress to your elbow and reinjure your UCL.

Weeks 25 to 56: You’ll work on a full return to sports, including throwing. You’ll work out any weakness in your arm or other body parts to improve your throwing motion.

New Elbow, New Dreams

Borak has made a comeback, but not quite the one he thought. He played baseball a few more years and still plays softball occasionally “to scratch that itch,” he says. But all that time in the gym led him to a new love: weightlifting.

In 2014 he was the Colorado state champion in his weight class, 85 kilograms. That wouldn’t have happened if he didn’t already possess an athlete’s work ethic. And it wouldn’t have happened without a rebuilt elbow.

“Elbow surgery isn’t for most people,” he says. “If it doesn’t impact their quality of life, they don’t need it. In my case, I wanted to get stronger, and I didn’t want to be limited, in any capacity, by an elbow injury that could be repaired. That’s what drove my decision to get Tommy John surgery.”

WebMD Feature Reviewed by Ross Brakeville, DPT on October 1, 2015

Sources

SOURCES:

Association of Surgical Technologies: “Ulnar Collateral Ligament Reconstruction.”

American Physical Therapy Association: “Major League Baseball Will Investigate Rise in UCL Tears, Possible Link to Youth Sports.”

American Academy of Orthopaedic Surgeons: “Remembering Frank W.  Jobe, MD.”

E. Edward Khalfayan, MD, orthopedic surgeon, Seattle Mariners, Seattle Seahawks.

Andrew Cosgarea, MD, orthopedic surgeon, Johns Hopkins University.

Tom Borak, UCL patient.

MLB.com: “Smoltz’s Hall message: Protect ‘future arms.’”

Drkhalfayan.com: “Tommy John Surgery/UCL Reconstruction.”

American Academy of Orthopaedic Surgeons: “Elbow Injuries in the Throwing Athlete.”

Johns Hopkins: “Johns Hopkins Shoulder Surgery Ulnar Collateral Ligament Reconstruction Rehabilitation Protocol.”

University of Wisconsin Sports Medicine: “Rehabilitation Guidelines for Elbow Ulnar Collateral Ligament (UCL) Reconstruction.”

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