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Elbow Throwing Injuries: The Medial Collateral Ligament (MCL) and Tommy John Surgery

An Interview with Dr. David Altchek

In the general population, injuries to the elbow are rarely caused by stress inflicted on the joint while throwing. But for serious amateur pitchers and their professional counterparts, who may be throwing the ball between 70 to 100 miles an hour, each pitch places a high degree of force on the joint. Over time, this repetitive motion can lead to inflammation, cartilage injuries, the development of bone spurs, and eventually tearing of the medial collateral ligament (MCL) of the elbow.

The MCL is part of a complex of ligaments and tendons that attach and stabilize the bones of the lower and upper arm where they meet at the elbow. Specifically, the MCL attaches the ulna – which, together with the radius, make up the bones of the lower arm – with the humerus, the bone in the upper arm. When the MCL is torn, the individual retains full range of motion in the joint and the ability to throw, but cannot exert significant force. MCL tears of the elbow are often the result of a gradual process of attenuation (weakening). It may not be immediately clear that the ligament has been torn, but some people report hearing a pop at the time of injury.

Image: Illustration of the medial collateral ligament (MCL) of the elbow.

Fortunately, surgical treatment of MCL tears often yields excellent results. Known by baseball fans everywhere as the "Tommy John surgery" – named for the pitcher with whom it is most frequently associated – construction of the medial collateral ligament benefits both professional and amateur athletes.

The surgery, first used to reconstruct the MCL in Tommy John's left arm in 1974, was developed by Dr. Frank Jobe. Since then, hundreds of athletes have undergone the procedure in which a tendon is taken from another part of the body and acts as a replacement for the injured ligament. The usual source for the tendon is the palmaris longus, a vestigial structure in the forearm. A second choice is the accessory hamstring tendon.

The palmarus longus is the usual source for the tendon in Tommy John surgery.
Palmarus longus

"Before Dr. Jobe developed this surgical technique, an MCL tear was often a career-ending injury," says David W. Altchek, MD, who is an associate attending orthopaedic surgeon at HSS. "Today, athletes that undergo MCL reconstruction often play as well as they did before the surgery, and, in some cases even better." It should be noted, Dr. Altchek adds, that non-athletes may also develop a full or partial tear to the MCL. However, because their daily activities are seldom affected, there is usually no need to undergo surgical treatment.

Today, athletes with MCL tears can benefit from refinements to Dr. Jobe's techniques that have been developed by Dr. Altchek and his colleagues at HSS. Dr. Altchek begins treatment with an arthroscopic examination of the affected area. (For more information on elbow arthroscopy, please see the link at the end of the article under Further Reading.)

After addressing any other conditions that are present in the joint, such as bone spurs, the orthopedic surgeon makes an incision to reveal the medial or inner aspect of the elbow joint. If possible, he or she then reattaches the remaining portion of the MCL. The harvested tendon graft is threaded through holes created in the ulna and humerus and sutured to stabilize the joint.

An illustration showing the insertion of the tendon graft in Tommy John surgery.
Illustration showing insertion of the tendon graft.

Dr. Altchek's technique differs from Dr. Jobe's in that only one hole is made in the humerus bone versus the three Dr. Jobe used. This offers a protective benefit to the bone which is more vulnerable to fracture if it has multiple holes in it. Dr. Altchek also found a way to simplify the tensioning of the graft and developed a special stitch that provides more secure fixation of the tendon to the bone.

During the original procedure, the orthopaedic surgeon took off the overlying muscles and moved the nerve away from the site in an effort to reduce the chance of injury. However, this approach carried the risk of trauma to both muscles and nerves. Today, orthopaedic surgeons are able to use a safer muscle-splitting technique that minimizes trauma to the muscles. Moreover, in most cases when Dr. Altchek performs the surgery, he does not find it necessary to move the ulnar nerve.

Adding to the safety of the newer technique is the shorter operative time. Traditionally, MCL reconstruction was performed over a period of about four hours; it can now be completed in about 30 minutes, thus reducing the chance of infection. Recovery from MCL reconstruction is lengthy. The patient must wait 9-12 months for the ligament to be healed into the bone. During this period, he or she participates in a rehabilitation program in which an increasing amount of force is gradually applied to the elbow and the muscles are strengthened. Most athletes can return to competitive play in a year.

Results of the surgery are generally excellent. In a recent study in which Dr. Altchek used the modified technique, 30 out of 31 patients who underwent surgery were able to return to their previous level of competition over an 11-month period.

While the incidence of MCL tears is high among elite major league baseball pitchers, Dr. Altchek points out that this is not the only population that experiences the injury. Women softball players may injure the ligament while playing catcher or short stop. Javelin throwers, lacrosse and tennis players, and golfers are also vulnerable, especially those who are middle-aged or older and may have some long-term degeneration of the ligament. In addition, children who participate in little league may injure the ligament. These tears are less frequent than in adults because young people do not throw as hard and their ligaments are more elastic; however, they do occur sporadically. Treatment in children may be modified owing to concern over protecting the growth plate in the joint.

Summary Prepared by Nancy Novick *Illustration of (MCL) provided courtesy of Bartleby.com


Headshot of David W. Altchek, MD
David W. Altchek, MD
Attending Orthopedic Surgeon, Hospital for Special Surgery
Co-Chief Emeritus, Sports Medicine, Hospital for Special Surgery

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