Tommy John surgery puts pitchers back on the mound

By Brian Hunsicker

Published: April 10, 2008

Dr. Tal S. David, an orthopedic surgeon in San Diego, recalled a study that showed that the force exerted on the ulnar collateral ligament on the average fastball was greater than the force it took to break that same ligament in lab tests. The ligament doesn’t break during pitching because some of the force is absorbed by the surrounding bone and muscle structure.

But when it does break, Tommy John surgery is the best way to fix it.

David compared the UCL to a fan belt. If you drive across the country twice, he said, the wear on the fan belt builds. It may fail on the third trip across the country or on a simple drive to the gro-cery store. The repetitive stress on the ligament is what leads to the break, not necessarily a single catastrophic event, he said.

The procedure is specific to athletes who throw. In most cases that’s a baseball player, but David said javelin throwers may also benefit from the surgery.

The operation was first performed on its namesake, then-Dodgers pitcher Tommy John, in 1974. The procedure uses a tendon somewhere else in the body — or perhaps even from a cadaver — to replace the injured ligament.

Dr. Robert Nirschl, an orthopedic surgeon in Arlington, said his preferred method for the proce-dure was to drill holes in the bones and thread the new tendon through the holes. Screws can also be used, he said; staples are riskier because of the chance they can become loose.

As the new tendon becomes incorporated, new blood vessels will reinvigorate the tendon, giving it life again. Nirschl likened it to a Christmas tree, which can survive without a water source. But if the tree is kept from water for too long, the needles will fall off and it will die.

The rehabilitation process can last as long as 18 months; Nirschl said in the early days of the Tommy John procedure, pitchers could be forced to sit out at least 18 months because there were no guidelines on how long recovery would take.

Nirschl divided the recovery process into three stages: rehabilitation, fitness and performance exercise. Rehabilitation, he said, gets the affected area back to normal. Fitness makes it better than normal. And performance exercise fine-tunes the area to perform specific tasks, whether it’s in baseball or occupational therapy.

Overcoming the mental hurdle is mostly an individual exercise. Nirschl said a doctor can help in that regard by hooking the patient up to a machine that measures workload, showing the patient that his or her elbow is as good as new.