To cut or not to cut: The Tommy John debate

A partial or complete tear of the ulnar collateral ligament (UCL) can be devastating to a pitcher of any level.  This ligament is the main stabilizer for the arm during the throwing motion.  Research shows that between 28 and 42 Nm of stress goes through the UCL with each pitch thrown.  The problem is that this is usually greater than the 32 Nm of force that the UCL can withstand during cadaveric testing.  Based on these numbers, the UCL should tear on just about every pitch that is thrown.  Obviously it does not, otherwise baseball would have died out as a sport a long, long time ago.  The opposing forces of the muscles surrounding the elbow as well as the core, leg, and rotator cuff, help dissipate the stress to the UCL and allow pitchers to throw well over 100 pitches per game without problems.

What is Tommy John surgery?

Tommy John was a pitcher for the New York Mets in 1974 when he suffered a tear of the UCL.  This injury was previously career ending (see Sandy Koufax) until Tommy met with Dr. Frank Jobe.  Dr. Jobe designed a surgery using a tendon from another muscle in the forearm to reconstruct the UCL.  The initial odds were 1:100 according to Dr. Jobe, but the procedure was a success as Tommy John was able to continue to pitch until 1989.

Rehabilitation after Tommy John

From surgery to full return to pitching takes approximately 1 year.  As we saw with Steven Strasburg, even when they return the first year, there should be a pitch and inning count that must strictly be followed to avoid placing the pitcher at risk of re-tearing the ligament.

Platelet-rich Plasma

Platelet-rich Plasma (or PRP) is a portion of the blood that contains platelets, which have healing elements and growth hormone present.  The person has blood drawn, which is then placed in a centrifuge to separate the red and white blood cells from the plasma.  This PRP is then injected into the injured area to promote healing. Looking for more info on PRP??? Check out this interview with a doctor in Cherry Hill, NJ http://3dpt.com/resources/medical-minute/148-dr-greenberg-4-29-2013

Matt Harvey’s decision

It is possible to rehabilitate and heal the damaged ligament with medical techniques today.  A study by Podesta, et al, from the American Journal of Sports Medicine took 34 pitchers with partial UCL tears and treated them with PRP and a comprehensive rehab program.  88% of these pitchers made it back to their prior level of play without reinjury, with an average return to play time of 12 weeks.

When Matt Harvey first was diagnosed with a partial tear of the UCL, most Mets fans that I know were crushed that their franchise pitcher and the future of the club would be shelved until at least the end of 2014.  The incorporation of PRP into treatment options gives Matt the chance of avoiding surgery, and pitching at the same level at the start of next season.  In addition to PRP, Matt will work with biomechanics experts and a team of physical therapists and strength and conditioning coaches to pick up flaws in his delivery as well as muscular tightness or weakness that place the UCL at an increased risk of injury.

All things considered, the conservative option is always preferred over surgery.  In this case, Matt has an 88% chance of rehabilitating, finding flaws in his mechanics and delivery, and making himself into a better pitcher than he was before coming back from this injury.  It is not a guaranteed success, but Matt should be back on the mound on opening day next season better than ever for the NY Mets.

 Ken Guzzardo, PT, DPT, OCS, SCS

Lit cited

Podesta, L, et al. “Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma”, American Journal of Sports Medicine, 2013, Jul, 41(7): pp 1689-94