Tommy John surgery or Ulnar Collateral Ligament (UCL) reconstruction is one of the most feared surgeries in baseball. The UCL reconstruction surgery got its name from the first patient, New York Yankees pitcher Tommy John. In 1974, Dr. Frank Jobe performed what was then an unknown surgery to try and save John’s career as an MLB pitcher. After the surgery, John would go on to continue pitching in the major leagues for years afterwards, and a new surgery was born.
Surgeries are created to fix a problem, but they are not meant to be a primary response. Amazingly, some people still believe that UCL reconstructive surgery will increase velocity in pitchers. This is not the case. Also, Tommy John surgery prevalence continues to increase every year, and patients are becoming younger and younger. The goal of medicine is to provide the minimal effective dose. Imagine that you have a really bad headache. You do not take 10 Advil even though that is probably more effective than taking 2. There are consequences of taking too much medication, so research tells you how many pills are necessary for the desired result. Unfortunately, UCL reconstruction is similar to taking a lot of Advil. It will probably fix your elbow, but there are consequences (we will talk more about them later).
We have now highlighted a brief history of UCL surgery, but it is important to understand that there have been alternatives attempted in the past. During UCL reconstruction, the ligament is completely replaced by a tendon from somewhere else in the body. Some surgeons have tried to simply repair the ligament, rather than fully replace it, but the results were not good.
However, technology has progressed and surgeons and researchers have begun to utilize new techniques including “internal bracing”. This involves essentially using tape to repair the damaged ligament without replacing it. We have come a long way in medicine in understanding what the body tolerates and will allow for healing, and the “tape” involves several biological factors that promote healing and are not rejected by your body. Pictured below is a rendering of an internal brace, courtesy of arthrex.com who are the makers of the brace.
You can see that the ligament is split, so the brace is sutured into the healthy ligament and provides a bridge over the damaged portion. This provides support for the tissue and allows for some self-healing to occur.
UCL Repair vs UCL Reconstruction
When comparing a new technique to an established one, it is important to see how the new technique provides a benefit. If there is no difference in regards to healing, recovery, or performance, then there is no need for a new technique. I want to highlight a few of the key differences and (in many cases) improvements provided by a UCL repair surgery.
First, it is important to understand how a UCL reconstruction is performed. The ligament in the elbow is replaced by a tendon from elsewhere in the body. The preference is to use the tendon from the palmaris longus muscle in the forearm, but not everyone has that muscle. Other useful tendons include the hamstrings and rarely the big toe extensors. There are two negatives to harvesting these tendons. The first problem is that there is now damage elsewhere in the body. While it may not seem like a lot, I have seen clients with hamstrings grafts have some residual weakness on the side that was utilized. There should be adequate time to strengthen the tissue, but it is still a limitation. The second problem is much more significant: a tendon is different from a ligament.
A quick anatomy review for you. Tendons are the connections between muscles and bones. Ligaments connect bones to bones. Structurally they are very different in regards to the materials as well as their functions. Unfortunately, surgeons are only able to harvest tendons at this point to replace ligaments. This is a similar process as an ACL reconstruction, where a tendon is used to replace a ligament in your knee. Interestingly, research shows that the tendon eventually takes on properties of a ligament in a process known as ligamentization, but this takes time. It is also important to remember that even though your own tissue is being used, it is still not the native tissue to your elbow. New tissue will never have quite the same properties of the old tissue whether that be for load tolerance or other measure. Think about your throwing motion. It is probably different from your friend’s. Do you think that you stress your UCL in the same way? Chances are that a surgeon would perform the same reconstruction technique on both of you, but there might be microscopic differences that your body has adjusted to over time that may not be addressed by surgery.
A limitation to UCL repairs is their usefulness is limited to certain biological characteristics. For instance, if you look at the elbow of a 35 year old major league pitcher, there is probably a lot of damage everywhere. There may not be enough strong tissue to anchor the internal brace and allow for healing. It may make more sense to just get an all new ligament rather than try and fix the old one.
Also, UCL repairs are very effective if the tear is on either end of the ligament because it can be anchored to the bone. Sometimes, the tear is in the middle of the ligament, which has less support for the brace and a surgeon may be less likely to be comfortable with a repair compared to a reconstruction. If the ligament is completely torn then a repair is also not appropriate, as the entire ligament needs to be replaced. UCL repairs show promise, but there are still significant limitations on the appropriate populations to which they should be applied.
UCL repairs are also a relatively new surgery. Fortunately, lab testing does show promising results. Cadaver studies show that the repair with internal brace has equal or greater resistance to stress compared to a reconstructed UCL. While this is encouraging, we still do not understand the exact relationship between elbow stability and throwing, as there are more forces with a pitch than the UCL can withstand in a cadaver. Clearly other tissues are involved and cadaver studies merely provide data points. The best information will come from retrospective studies from the athletes who received the surgery and how they are performing several years after surgery.
UCL Repair with Internal Brace
To summarize the previous section, the ideal pitcher to receive a UCL repair with internal brace is a younger player with a healthy elbow who suffered a partial tear on either end of the ligament. Fortunately, the repair also provides a benefit to younger athletes who are still growing. In traditional UCL reconstruction surgery, holes need to be drilled into the bone to allow for the anchoring of the new ligament. The ends of long bones typically include the growth plate, which is the area of bone that is responsible for lengthening. It is typically softer and more prone to damage (such as in Little League elbow or shoulder). Damage to the growth plate can affect growth on that side, leading to a premature closure and stunted growth. There are surgical techniques to spare the growth plate, but they may compromise on stability of the surgery. UCL repairs are an attractive option because they do not require damage to the growth plate or bone.
UCL Repair Recovery
As I mentioned above, it is important to provide the least invasive intervention possible. There are three grades to a ligament sprain. Grade 1 involves minimal damage to the ligament itself, and 93-100% of athletes recover with only conservative treatment. Grade 2 involves a partial tear, and this would be a candidate for a UCL repair. Grade 3 is a full tear, and this will usually require reconstruction. It is important for you to understand what happened in your body so that you can make the best decision for rehabilitation.
The most exciting part of UCL repair surgery is the timetable for return to sport. In a study by Jeffrey Dugas, one of the pioneers of this technique, he found that 96% of athletes who underwent a UCL repair surgery returned to play. They also returned in an average of 6.1 months. This is obviously very different from the typical 12-18 month recovery from a UCL reconstruction for major league pitchers.
You can understand part of the reason that recovery is so rapid. The lack of disruption of native tissue is crucial. Typical Tommy John surgery requires weeks of little to no movement to allow the new ligament to heal and begin the process of ligamentization. Within a week after UCL repair athletes are actively moving their elbow. There is minimal motion loss that needs to be addressed through physical therapy because there is not enough time for motion to decrease. There is also significantly less swelling which is crucial to maintain motion.
Strength can also be difficult to obtain after inactivity. UCL reconstructions require months without heavy lifting for the affected arm. Part of the elongated timeline to return to throwing is because it takes so long to build up strength, not to mention throwing tolerance. A more simple repair significantly reduces the downtime that leads to restrictions and atrophy, allowing for faster return to sport.
UCL Repair Physical Therapy
The exact protocol for UCL repair is difficult because it is essentially the timeline for a reconstruction but expedited. Typically, a brace is worn after surgery for 4-6 weeks to limit motion and allow for healing at the site. Some physicians will discontinue the brace before that time, as the healing site is relatively safe as long as there is not violent motion. The early goals of physical therapy for the first 4-6 weeks include soft tissue mobilization and range of motion exercises. Passive exercises are allowed throughout, so full passive range of motion should be achieved relatively early.
As with all physical therapy, this is a great time to analyze strengths and weaknesses along with the cause of injury. While you will not be sidelined as long as you would for a UCL reconstruction, this is quality time to work on lower body and core strength. It is important to take a step back and look at qualities such as workload which may have led to the injury. Physical therapy should not just focus on mobilizing and strengthening the elbow, as there are often other factors that lead to elbow stress.
At about 6-8 weeks some light strengthening of the elbow musculature including the biceps, triceps, and forearm muscles is usually allowed. Stressful exercises including biceps curls and other movements that create force on the elbow including chest flys are typically delayed until 12 weeks to allow for full healing. Light plyometric exercises can begin at 6-8 weeks with gradual load and intensity progression. A throwing program usually begins at the 12 week mark, as long as other criteria have been met based on mobility and strength of the throwing arm. A throwing program should be gradual with extra time built in due to possible setbacks. The timeframe from 12-24 weeks should allow for building an adequate throwing workload. Pitchers will typically require more time, but it depends on the individual. At this point, the physical therapist should be in communication with any pitching or throwing coach to allow for an individualized return to play plan for the athlete.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about UCL repair and reconstruction and how they differ. If you want to learn more about elbow injuries, check out our elbow page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at danny@eclipsewellnessnova.com or follow me on Instagram or Twitter @drdannydpt.