Ulnar Collateral Ligament – Elbow Surgery (Tommy John)

Learn about UCL Elbow Surgery elbow surgery Ulnar Collateral Ligament - Elbow Surgery (Tommy John) Baseball PitcherElbow Surgery (Tommy John) – Ulnar Collateral Ligament

Contributed by Stephanie Thomas, COF

To coincide with 2017 Opening Day, we decided to shed some light on a procedure we see quite often that is related to baseball and more specifically pitchers. In fact, a professional pitcher was the first person to have this elbow surgery about 40 years ago.

Who is Tommy John?

In 1974 Los Angeles Dodgers’ pitcher Tommy John was having a great 11th season in the Majors, starting 13-3. Many believed he would eventually be a Cy Young Award winner, but he damaged his ulnar collateral ligament (UCL), which is a ligament of the elbow. He was adamant about returning to baseball. John went to the team physician, Dr. Frank Jobe and asked him to develop an elbow surgery that would fix his UCL and allow him to pitch again. Dr. Jobe developed a technique that allowed John to return to pitching in 1976. Since then there have been different techniques developed to help repair the UCL.


Original Procedure – During Dr. Jobe’s procedure, he would harvest the patient’s palmaris longus in the wrist. It is important to note that not everyone has a palmaris longus; if the patient doesn’t have this ligament the surgeon may opt to harvest a different autograft (from patient’s body) such as the gracilis, plantaris, or a strip of the Achilles to complete the elbow surgery.[1] You can test yourself by touching your thumb to your ring finger and twisting your wrist. The ligament will pop out (like the photo) if you have it.

Ligament used for Elbow Surgery elbow surgery Ulnar Collateral Ligament - Elbow Surgery (Tommy John) ligament in arm for elbow surgeryDr. Jobe utilizes the Figure 8 technique where he would drill two holes in the medial epicondyle and two holes into the ulna and feed the palmaris longus through. Then he would suture the tendon to itself. He also had to detach the flexor-pronator musculature at its origin which would cause the ulnar nerve to transpose.[2]

Docking Technique – This technique, developed by Dr. David Altchek, it is different from the original technique in many ways. First it does not detach the muscle group, instead, it uses a muscle splitting technique. This procedure also does not drill as many holes, and the tendon is shaped into an “elongated D” instead of a figure-8. The tendon graft enters the humerus but never exits and is sutured to the bone.[3]

What are the Signs and Symptoms of Ulnar Collateral Ligament Injury?

You may feel a “pop” on the inside of the elbow that is accompanied with pain and possible swelling. You could also notice that you are weaker when throwing. Always make sure you have your injury evaluated by a healthcare professional; an MRI may be ordered to determine if there is a tear in the ligament that requires elbow surgery.

Who should have “Tommy John” elbow surgery?

Surgical intervention should be discussed with your physician. There are conflicting ideas on how early is too early to for an athlete to have this procedure. Many believe that high school athletes should not have the surgery due to some athletes still growing, where others believe it is ok. You should also ask the doctor what type of technique he/she will be performing.

Treatment and Rehabilitation

If you decide to have “Tommy John’s” elbow surgery, you will be placed in an elbow range of motion orthosis, after the procedure, (we use the Breg T-chek, seen below) to help protect the elbow and to eliminate movement. The orthosis is also adjustable to allow for a controlled range of motion. When the time comes, you will begin physical therapy and rehabilitation to get back to throwing again. This whole process can take over a year. Discuss the timeline with your doctor.

 

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References

[1] Ellattrache N; Harne C; Mirzayan R; Sekiya J. Surgical Techniques in Sports Medicine. Lippincott Williams and Wilkins. 2007.

[2] Vitale M. Ahmad C. The Outcome of Elbow Ulnar Collateral Ligament Reconstruction in Overhead Athletes: A Systematic Review. Am J Sports Med. 2008;36:1193-1205.

[3] Borak T. Ulnar Collateral Ligament Reconstruction: A Look Inside Tommy John Surgery. The Surgical Technologist.2009;41:163-172.

Plagiocephaly and Cranial Remolding Helmets

Cranial Remolding Helmets for plagiocephaly have become more and more in demand since it has been known that it is safer for an infant to sleep on his/her back. During the early stages of development, the skull is vulnerable to any outside pressure, causing it to change shape. My hope is to educate you more on what to expect if your pediatrician/specialist has recommended or prescribed your child a Cranial Remolding Helmet and answer any questions you may have.

When is a cranial remolding helmet necessary?plagiocephaly and cranial remodeling helmets plagiocephaly Plagiocephaly and Cranial Remolding Helmets Top View 3 Helmets

A doctor or specialist typically prescribes a helmet because the child has been diagnosed with the following:

  • Plagiocephaly: typically the result of torticollis of the neck and the infant is usually laying with their head always to the same side
  • Brachycephaly: caused by infant laying on his/her back and the back of the head becoming flat
  • Scaphocephaly: infant’s head is constantly rolling side to side, causing the head to be elongated

If your child is diagnosed with plagiocephaly, brachycephaly or scaphocephaly, therapy may be prescribed for infant, as well as changing of the sleeping arrangements. Both of which should be discussed with the pediatrician/specialist.

At what age does a child wear the helmet?  

Most of the infants we see range in age from three months to nine months. The younger the patient the more potential there is for head growth during the therapy. Since there is more growth at a younger age, the child may not have to wear the helmet quite as long as they may have if they were older. Another factor to consider is that older children have a greater ability to grab and possibly remove the Velcro® strap holding the helmet together (Note: helmet will not fall off if the strap is removed but will not be closed completely).

Does Insurance Cover cranial remolding helmets?*

It is very common that insurances do require conservative treatment before they will provide coverage for the Cranial Remolding Helmet. They typically require at least six weeks of conservative treatment which can include re-positioning in the crib and therapy. Therapy can include a physical therapist and/or occupational therapist stretching the neck muscles so the infant does not tend to turn to one side or the other.

Insurance also bases coverage on whether or not the measurements of the infant’s head fall into the moderate to severe range on the Cranial Vault Asymmetry Index (CVAI). If your child’s measurements are in that range then there is a good chance the helmet will be covered. These measurements would be taken at your first evaluation (which is free!).

What does an appointment entail? 

During your first appointment, we go through the history of the pregnancy; we also ask about any complications during delivery. After the history is taken, then measurements of the head are recorded.  Next, a stockinette is placed on the child’s head and the orthotist uses a laser scanner around the head to obtain a 3-D picture.

Based on the measurements, we then decide if a helmet is necessary; if not, we can set up another appointment to re-evaluate and see if the condition has worsened. The scans are only viable for 2 weeks; after that time, if a helmet is to be ordered, new measurements and scan must be obtained. Once the measurements and scan are collected and the child’s measurements fall in the moderate-to-severe range. then we order the helmet.

How is a helmet fitted? 

Once the helmet has been received from Boston Brace, we set up the fitting as quickly as possible. After the first fitting, we setup up bi-weekly appointments for either new measurements and/or scans to check progress. Adjustments of the helmet are then made at that time. Typically the helmet is not needed once the patient has measurements in the mild-to-moderate range and/or the parents are satisfied with the results.

Baby helmets for plagiocephaly  plagiocephaly Plagiocephaly and Cranial Remolding Helmets Front View 3 Helmets

*All helmets require a signed prescription from a physician or specialist. Coverage is based on individual plans and may be subject to a deductible.*

We are glad to answer your questions about plagiocephaly and other conditions that are treated with Cranial Remolding Helmets.

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Carpal Tunnel Syndrome: Is Surgery My Only Option?

What is Carpal Tunnel Syndrome?

Carpal Tunnel Syndrome carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? wrist pain 5 1411498The carpel tunnel is where the median nerve, various tendons, and muscles cross over the palmar side of the wrist and hand. Since it is such small space, once one of these structures is irritated numerous problems can arise.

The most common symptoms of Carpal Tunnel Syndrome (CTS) are numbness and tingling in the hands and fingers as well as pain on the palmar side of the wrist. There are varying degrees of severity of CTS but, if found early, conservative treatment can be an option.

Is Surgery the Best Option?

Anytime your doctor mentions the word surgery, there are so many questions that need to be answered:

  • How long will I be under anesthesia?
  • What are the risk factors?
  • Will it be worth it?
  • Will it work?
  • Will I be off work? If so how long?
  • How will this affect my daily life?

With all of these uncertainties sometimes surgery does not seem to be the best option at that time. Sometimes we want to explore the more conservative treatment options because choosing to have surgery is a major decision. Depending on the severity of your symptoms, surgery may be the best way to relieve your symptoms but there are other ways to manage the symptoms of carpal tunnel syndrome and talking to your doctor about your situation will help you determine your needs.

Managing Carpal Tunnel Syndrome

The most common management of the symptoms is to wear a wrist brace. It needs to be a Wrist Cock Up Splint (WCUS) that keeps the wrist in a neutral position (slightly extended).  This will help keep the median nerve from being pinched or compressed to alleviate any irritation.  Most people wear the wrist brace(s) while sleeping since we like to flex our wrists when we are asleep. If you are having pain while awake or with activity it is okay to wear the brace(s) then.

Other treatment techniques that can help manage your pain, along with the wrist brace, are yoga, hand therapy, and ultrasound therapy. You can also use these daily movement/stretching techniques offered by sportsmedpress.com:

Help for Carpal Tunnel pain carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? carpal tunnel movements

Movement: Gently move your wrist from side to side in a handshake motion. Hold for 5 seconds on each side. Repeat 10 times. Do 3 sets.

Grip Strengthening for Carpal Tunnel Syndrom carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? Grip Strengthening for Carpal Tunnel e1482123991998Strengthening: With a rubber ball in your palm hold a squeezing grip around the ball for 5 seconds. Repeat 10 times.

Learn carpal tunnel syndrome exercises carpal tunnel Carpal Tunnel Syndrome: Is Surgery My Only Option? carpal tunnel syndrome relief
Stretching: Place both palms on a flat surface. Gently lean body forward over your wrists and hold for 20 seconds. Repeat 3 times.

If you have questions, you can call Bioworks at 513-793-7335 or complete our <a href=”https://cryptnsend.com/bio1/bio1.php”>contact form</a>.<em> As always, you should consult your primary care physician before beginning this or any treatment or exercise routine. </em>

(Photo credit: www.freeimages.com photographer: Carpal Tunnel Gadgets)