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Thumb UCL Sprains – Understanding Mike Trout’s Injury

Mike Trout, the Los Angeles Angels’ star outfielder, will undergo surgery tomorrow for a torn ulnar collateral ligament (UCL) in his left thumb. The injury occurred – as most of these do in baseball – when the 25 year-old slid into second on a stolen-base attempt on Sunday. Trout, who throws and bats right handed, had an MRI later that day that confirmed the tear. This will be Trout’s first stint on the DL and it will be for a significant period. Read More ›

Lucas Duda – Explaining Elbow Hyperextension Injuries

Mets’ first baseman Lucas Duda suffered a hyperextended left elbow in the fifth inning on Wednesday when Cesar Hernandez, the Phillies’ second baseman, tried to run out an infield hit up the first base line and ran into Duda’s glove with his left shoulder as he fielded the throw from the pitcher. Though he remained in the game through the half inning, Duda was removed for a pinch hitter in the bottom of the fifth. Duda will likely have an MRI today to determine the extent of his injury.

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Questions Remain on Beltran and Tanaka

Though Carlos Beltran has said he felt ready to go, before spring training began, Joe Girardi is reportedly taking it slow with the 38 year-old veteran right fielder, planning to play him for the first time on Friday. Well, though that is only 3 days into the spring training game schedule – not a significant delay – I still don’t get why Beltran waited until September 30th to have loose bodies and a bone spur removed from his right elbow. With the 2014 season going nowhere, an established need for surgery, and his personal numbers taking a hit (.233/.301/.402 with 15 home runs and 49 RBI in 403 at-bats), why the push to wait until the off-season?

In Beltran’s defense, he and the Yankees’ medical team may have decided that since the surgery required only the removal of structures – rather than any type of repair – that the recovery process would not be hampered by the need for the important tissues of the area to undergo a lengthy healing process. That is generally true of surgeries like the one Beltran had, as opposed to procedures that entail restoring function after any type of reconstruction or repair of muscle, tendon or labrum. Beltran should be fine (and he’d better be if he will have to throw from right field rather than DH).

However, despite that, it seems more prudent to me – particularly with older players who may require more healing time – to opt for surgery earlier and allow for a longer period of rehab; particularly in a non-playoff situation. This ensures the best possible recovery and minimizes risk of returning to play (even practice) sooner than medically desirable.

As for Tanaka…

The Yankees are certainly taking more of a crapshoot with starting pitcher Masahiro Tanaka, who sustained a partial ulnar collateral ligament tear last season. Tanaka returned at the end of the regular season to pitch two games after a lengthy absence. Despite his effectiveness in those appearances and his progress to date, even GM Brian Cashman stated rather candidly “If Tanaka’s healthy he’s going to be successful, I know that. If not, it will declare itself over time and we’ll deal with it.”

Let’s face it; the fact that Tanaka and his pitching coach, Larry Rothschild, have been pleased with his bullpen sessions to this point is by no means indicative of the way his season will go. Tanaka has been ramping up the force with which he pitches while reportedly improving his location and limiting his number of tosses. Though Tanaka claims to be “on the right track”, even a cautious rehab and return to the mound far from guarantees his success.

Few have succeeded in returning from UCL injury after conservative management alone. I hope to be proven wrong for having suggested that Tanaka would opt for the more aggressive approach of surgery first. It seemed to me that he would be ready to pitch at some point this season – even if only toward the latter portion – with little risk of sacrifice of an additional year. Now, who knows? It does seem likely that Tanaka – a fastball pitcher with an injury such as this so early in his career – is destined for Tommy John surgery. The real question is, if not now, when?

Follow Abby Sims on Twitter @abcsims.

Tanaka’s Elbow: An Uncertain Outcome

Masahiro Tanaka, now on the DL with a diagnosis of a partial ulnar collateral ligament (UCL) tear in his right elbow, got a consensus of opinion as to a plan of care when he was saw three specialists on Thursday.  The good news was that they agreed on managing the injury conservatively rather than jumping right to surgery. That is clearly an indication that the tear is relatively small.  However, it seems, as it generally does, that though the course of treatment may be conservative, the estimate for the player’s possible return to action is anything but. 

As I’ve written before, even with rest, PRP (platelet-rich plasma) injection and rehab, a torn ligament does not regain full tensile strength in a matter of weeks. And, pitching – especially at full velocity – before it does so puts the already weakened tissue at further risk. Though we all root for a successful outcome for the young Yankees’ All Star, saying that if he is able to return in six weeks, Tanaka will avoid surgery, may be pushing it. 

We’ve seen other pitchers attempt to rebound from UCL tears without undergoing Tommy John surgery. Few succeed. A very small tear – if that is what it is – improves Tanaka’s chances of being one of the outliers. However, even if he makes it back before the end of this season, we’ll only know if the pitcher is able to escape without treating the elbow more aggressively if it stands up to repeated stresses once he returns to the rotation. How he performs, not just initially, but over time would clearly be the key.

The six-week timetable for Tanaka’s recovery that has been reported in the media may simply be in play to make the decision to opt for surgery more straightforward. If his condition hasn’t sufficiently improved by then, there is always Plan B. Surgery clearly offers a more decisive outcome.

Dr. James Andrews’ outlined his thoughts on the epidemic of Tommy John surgeries in a recent position paper, in which he also addressed the ways in which UCL injuries might be avoided.  The cumulative effects of the demands of youth programs can only be modified for the pros of tomorrow.  For Tanaka, being mindful that pitching without sufficient rest, when fatigued and at consistently high velocities increases risk. Always pitching full out in bullpen and flat ground sessions may contribute to the vulnerability of the ligament.

So will hastening his return.

Follow Abby Sims  on Twitter @abcsims.

UCL Rehab Can’t Be Rushed: Listen Up Matt Harvey!

It is difficult to understand what’s been going through Matt Harvey’s mind, even taking into consideration his competitive nature. In the fall he thought that he – unlike just about any other pitcher with a UCL tear – might be able to avoid Tommy John surgery.  It seemed the Mets almost had to push Harvey to fail in order to convince him to pass up the season and go under the knife.

And now, after having undergone the procedure on October 22nd, Harvey hoped to rush his return, jabbering about pitching in August and September to be able to see how well he performs rather than wait and wonder through the off-season. Contradicting himself all the time, Harvey had previously been quoted as saying that though he wouldn’t want to jeopardize his career by coming back too soon, if the Mets were in it in September he would accelerate his return. Though only five games back in the division, the team is currently riding a six-game losing streak. For better or worse, it doesn’t appear there will be any extra incentive there.

Thankfully, the Mets have not caved to Harvey’s pressure and sense has prevailed, delaying the pitcher’s sessions off the mound that were to commence this week.

In prior posts I’ve taken a look at the nature of UCL injuries and Dr. James Andrews’ position on the current epidemic of Tommy John surgeries amongst pitchers. I’ve written often of the risks of playing too soon and, unfortunately, my predictions of doom have been borne out by a long list of players across multiple diagnoses, including Mark Teixeira, Derek Jeter, Kobe Bryant and many more.

Healing takes time and the body can’t be rushed. Feeling good without the demands of an activity likely to offend is not a predictor of ultimate success. Not even a little. Though his musculature can be coaxed back to full capacity, Harvey’s new ligament isn’t likely to be at full strength until October. Rushing through a throwing program and pitching too often, at high velocities and at full capacity won’t hasten his recovery but will prove to stress his new UCL beyond its capacity. Unless he’d like to face a revision surgery down the road – perhaps sooner than later – Harvey would be wise to take direction from his medical team without a fight.

Follow Abby Sims on Twitter @abcsims.

 

Dr. James Andrews Explains The Tommny John Epidemic

Dr. James Andrews, the renowned orthopaedic surgeon who founded Birmingham, Alabama’s American Sports Medicine Institute (ASMI), is one of the go-to guys for baseball players throughout the country when they suffer from shoulder or elbow issues. Last week Dr. Andrews published a position statement to explain the current “epidemic” of pitchers’ ulnar collateral ligament (UCL) injures and the resultant Tommy John surgeries.

The Tommy John procedure entails the reconstruction of the elbow’s UCL – which is the ligament that stabilizes the inner aspect of the joint.

Andrews details the risk factors that predispose adolescent pitchers to UCL wear and tear. The primary concern is simply doing too much too soon. That includes competing year-round, doing so on multiple teams,

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pitching while fatigued, and playing catcher when not pitching, which also necessitates repetitive throwing.

Additional factors discussed include improper mechanics and poor physical conditioning. Whether in youth ball or at the major league level, pitchers consistently exhibiting the highest velocities are reportedly at greatest risk for UCL injury.

In order to reduce risk, recommendations included:

  • Incorporating a biomechanical analysis to aid in optimizing pitching mechanics and establish a baseline. Utilizing the whole body properly to maximize performance should be emphasized.
  • Varying pitch speeds while focusing on control and mechanics. The goal should NOT be maximal effort with each pitch, whether on the mound, participating in throwing drills or during bullpen sessions.
  • Enhancing communication between pitchers, coaches and the medical team to monitor players’ response to pitching and adjust care and activity accordingly. Andrews notes the need for adequate rest, hydration and nutrition to heal the small tears in the tissue that normally occur with pitching. Any unusual symptoms or adverse reactions should be cause to modify activity.

Note that

this is also why recovery time is recommended for anyone doing strength training. It is the healing of the microscopic tears in the tissue that results in the building up rather than further breaking down the muscles being trained.

  • Avoiding pitching while fatigued, whether in-game or during bullpen sessions.
  • Considering rest and recovery time rather than winter league participation.
  • Staying away from PEDs and the excessively strong musculature that can result from their use, causing the UCL to break down because of heightened demand.

Dr. Andrews went on to discuss a number of fallacies often blamed for placing undue demand on pitchers’ UCLs. Two of these are that:

  • The curveball as a prime offender. Though research has not shown curveballs to be at fault for the mature pitcher, young pitchers may not possess the physical ability, or have had the proper instruction to master this pitch safely. Therefore, Dr. Andrews recommends young pitchers focus on developing a fastball after learning good general throwing mechanics and before adding a curveball.
  • The height of the mound is a causative factor. Research has shown that torque on the elbow when pitching with full effort does not differ whether on the mound or flat ground. It is the velocity and effort that is the issue.

Follow Abby Sims on Twitter @abcsims.

 

An Elbow Drags Another Pitcher Down: The Partial UCL Tear

After hearing that Mets’ closer, 29 year-old Bobby Parnell, was diagnosed with an incomplete medial collateral ligament (MCL) tear in his right elbow, one jumps to the logical conclusion that surgery is in his immediate future. That is especially so with a team physician – Dr. David Altchek – who pioneered a very successful modification of the original Tommy John procedure.

The first thing to realize is that the medial collateral ligament of the elbow is also known as the ulnar collateral ligament – or UCL – because of its attachments to the humerus and ulna at the inner (medial) elbow. Now that you know that, the first thought of any Mets’ fan might be that Matt Harvey recently succumbed to surgery to address the same injury (though perhaps the extent of the tears is not identical). Both men complained of primary symptoms in the forearm.

Matt Harvey resisted the knife initially and now, evidently, Parnell is following suit. The Mets tweeted that after having a Platelet Rich

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Plasma (PRP) injection, Parnell will rest for two weeks before beginning a throwing program, after which it will be determined whether surgery will be required.

Well, what do you think the outcome will be?

First, consider that even a partially torn ligament does not heal in two

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weeks. In fact, complete healing might take a year. The tensile strength of the healing tissue is significantly impaired during the healing phase and is only at about 80% of capacity at the three-month mark. Will PRP accelerate things that much? Even if effective, that isn’t likely.

Next, keep in mind the extraordinary stresses that pitchers place on the medial (inner) elbow — and the excessive loading of the region — which can create inflammatory or degenerative conditions in a number of structures in the area. This may explain why Parnell’s symptoms – like Harvey’s – were not initially localized to the UCL, which is the primary stabilizer of the elbow.

Other tissues often affected include the wrist flexor muscles — which are in the forearm but whose tendons attach at the inner elbow — the forearm pronators (which turn the palm downward), the elbow joint capsule and the ulnar nerve. The repetitive demands of pitching and the nature of the motion itself — particularly the acceleration phase — are the primary culprits.

A partial tear of the UCL — also referred to as a moderate (Grade 2) sprain — causes laxity (looseness) of the ligament. This, in turn, creates joint instability. The resulting instability places even greater stress on the surrounding tissues. Even after the cumulative trauma of less significant Grade 1 injuries (micro-tears), ligaments may be weakened and tissues prone to inflammation. At worst, they could tear further. Additionally, other degenerative changes such as bone spurs may result.

So, placing excessive demand on weakened structures that were vulnerable even when at full capacity – in other words, pitching – doesn’t sound like a recipe for success. The two weeks of rest sounds like a smoke screen to me and, like so many other pitchers who’ve already fallen to elbow issues at this early stage of the season, I wouldn’t expect Parnell to take the mound for the Mets until 2015. If he does, it may not be for long.

Follow Abby Sims on Twitter @abcsims.

Matt Harvey’s Partial Tear: Surgery Now Or Chance It?

If Matt Harvey was an everyday guy pitching in a Central Park League and he opted to try conservative management after partially tearing his ulnar collateral ligament (UCL), we wouldn’t give it a second thought.

With an uncertain outcome either way – and greater overall risks with surgery – what would he have to lose? It wouldn’t be as though his livelihood depended on the result. And, after all, if rehab alone didn’t wind up being the answer, surgery could be done later. The primary downside would be time spent or, depending on how you look at it, time lost.

My point exactly. It also appears to be a point made by Mets’ management, though the choice has rightly been left to the All Star.

Harvey will now reportedly weigh Dr. James Andrews’ opinion in with the others he’s received before deciding whether to opt for right elbow surgery. Though much has been written about Harvey’s consultation with the Phillies Roy Halladay – who continued to pitch with much success after non-surgical management of his elbow issues in 2006 – it has also been reported that Halladay evidently did not have a significant tear. It appears his symptoms may have been due primarily to muscle and/or tendon pathology rather than ligament. Still, he took a calculated risk that might not have had a happy ending.

Harvey was quoted as saying that his elbow is feeling great now. That is most definitely a positive, but not only is he likely receiving treatment, the fact that he hasn’t been pitching is certainly relevant. Minus the demands pitching normally places on it, Harvey’s

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elbow is evidently not so acutely painful that routine activities of daily living are problematic. Though I get his ambivalence, that may not be enough of an overriding factor to justify ruling out surgery.

However, we’ll soon see how the majority rules. Mark Teixeira is one of a number of players who, with perfect hindsight, might like a time machine to reverse his chance-it-and-see versus surgery-now decision. Granted, he had a different injury, but that doesn’t make him any less of an illustration. There are a number of others who’ve had Teixeira’s experience.

It takes up to a year for a ligament to heal, and, because it is the primary stabilizer of the elbow, a weakened UCL creates stresses to other tissues in the area. Rehab will be considerable whether Harvey has surgery now or not, but the threat of having to do it twice looms large.

For more on the UCL and Tommy John surgery, take a look at this prior column on Harvey.

Follow Abby Sims on Twitter @abcsims.

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Understanding Matt Harvey's Partial UCL Tear

Matt Harvey, the New York Mets’ 24-year-old ace, has been shut down with a partial tear of the ulnar collateral ligament (UCL) in his right elbow. Manager Sandy Alderson revealed that though Harvey had been experiencing forearm troubles for “some time” and was undergoing treatment throughout the season, he had not previously complained of elbow pain. The All Star is likely headed for Tommy John surgery, though that has not been established with certainty.

The extraordinary stresses that pitchers place on the medial (inner) elbow – and the excessive loading of the region – can create inflammatory or degenerative conditions in a number of structures in the area. That may explain why Harvey’s symptoms were not initially localized to the UCL, which is the primary stabilizer of the elbow.

Other tissues often affected include the wrist flexor muscles (which are in the forearm but whose tendons attach at the inner elbow), the forearm pronators (which turn the palm downward), the elbow joint capsule, and the ulnar nerve. The repetitive demands of pitching and the nature of the motion itself — particularly the acceleration phase — are the primary culprits.

A partial tear of the UCL – also referred to as a moderate (Grade 2) sprain – causes laxity (looseness) of the ligament. This, in turn, creates joint instability. The resulting instability places even greater stress on the surrounding tissues. Even after the cumulative trauma of less significant Grade 1 injuries (micro-tears), ligaments may be weakened and tissues prone to inflammation. At worst, they could tear further. Additionally, other degenerative changes, such as bone spurs may result.

A Grade 3 UCL sprain is actually a complete tear of the ligament. As in the case of less severe sprains, these can occur traumatically, as with an isolated pitch or in the event of elbow dislocation. However, for many pitchers, earlier injuries bring about the perfect storm.

Dr. David Altchek, orthopedic physician for the New York Mets, and co-chief of the Sports Medicine and Shoulder Service at New York's Hospital for Special Surgery, pioneered a radical modification of the Tommy John procedure that is now the gold standard.

The original surgery, first performed by Dr. Frank Jobe in 1974 on Tommy John, then of the L.A. Dodgers, involved using a tendon graft harvested from the patient and weaving it in a figure eight pattern through channels created by drilling three holes into the bone. To do so, muscles were detached and the ulnar nerve had to be moved.

The newer technique, known as the docking procedure is less invasive, entails splitting the muscles rather than detaching them, requires that only one hole is drilled and allows the ulnar nerve to remain in place. Success rates exceed that of the traditional approach, though pitchers still are progressed cautiously and on average return to competition just prior to the anniversary of surgery. Success is determined by restoring pre-injury levels of performance rather than time to return.

It was hoped that Matt Harvey would be a solid part of the foundation upon which the Mets hope to build. Unfortunately, Mets’ fans are in for some more delayed gratification.

Follow Abby Sims on Twitter @abcsims.

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Joel Hanrahan: Flexor Tendon versus UCL

31 year-old closer, Joel Hanrahan, has had a rough start to his tenure with the Red Sox after being acquired from the Pirates in the off-season. Now we know why – a torn flexor tendon in his right elbow. According to Julian Benbow of the Boston Globe, the pitcher is slated for surgery to repair the tendon. Hanrahan also reportedly acknowledged that, though his MRI did not show evidence of an ulnar collateral ligament (UCL) tear, there is always the possibility that once Dr. James Andrews is in the joint, it will be determined that the UCL is involved. If so, he will also requires a Tommy John procedure. MRI’s are not perfect, and if the ligament is involved, it won’t be much of a surprise. Let’s look at why…

The Common Flexor Tendon

Tendons are the extensions of muscles that connect them to bone, while ligaments connect bone to bone in order to provide stability at our many joints.

There are a total of nine muscles located in the palm

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side of the forearm. Some play a role in flexing the wrist or fingers, while others rotate (pronate or supinate) the forearm. Some of these also assist with bending the elbow. These muscles are divided into three layers. The five in the most superficial and middle layers all attach at the medial (inner) elbow in what is known as a common flexor tendon.

Two of these muscles – Flexor Carpi Ulnaris (FCU) and Flexor Digitorum Superficialis (FDS) – overlap the ulnar collateral ligament of the elbow (UCL). This is the ligament of the inner elbow that often tears in throwing athletes, requiring Tommy John surgery. The FCU is especially positioned over the ligament when the elbow is flexed at a right angle. Due to their location and function, these muscles are considered to assist with the dynamic stabilization of the inner elbow.

Ulnar collateral ligament injuries occur in throwing athletes because of the extreme and repetitive loading on the inner elbow during the pitching motion. This stress (referred to as a valgus stress) is greatest just after the cocking phase. Take a look at this picture, and you will see why.

The acceleration phase of pitching also results in a good deal of valgus stress at the elbow. Muscular activity of the FCU and FDS is also heightened during this phase, continuing to put these flexors at risk.

When a tendon is torn, the ability of the attached muscle to exert the necessary forces is obviously impaired. Of course pain is also likely. A corollary is that with an ulnar collateral ligament injury, the activity of the FCU and FDS, as well as that of another of the flexors (Flexor Carpi

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Follow Abby Sims on Twitter @abcsims.

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