Elbow

What kind of injury leads to Tommy John surgery?

Tommy John surgery refers to reconstruction of the elbow’s ulnar collateral ligament (UCL), so named since the first of these procedures was done on LA Dodgers pitcher Tommy John in 1974.  The anterior band of the UCL is a strong, cord-like ligament on the inner aspect (near the “funny bone”) of your elbow.  It can be injured traumatically or, more commonly, in athletes involved in repetitive overhead sports, particularly throwers.  Sudden injuries occur with trauma, frequently due to elbow dislocations. While a sudden injury to this ligament can also result from throwing, our throwing athletes more commonly develop a gradual degeneration of this ligament which can ultimately leave it too weak to sufficiently stabilize the elbow through the normal throwing motion.  When this happens, rarely is there sudden onset of pain.  Rather, a gradual soreness develops and velocity and location can suffer as a result.  This can also happen to quarterbacks, volleyball hitters and tennis players although it is less common and often less problematic in these athletes than in baseball players.

Why does this ligament tear in pitchers?

Research into the causes of UCL injuries in throwers is not clear cut in terms of pitch count, types of pitches thrown, etc.  What is clear, however, is that a high volume of throws coupled with higher throwing forces (and velocity) will contribute over time to stress and cumulative injury of the ligament.  Less than ideal throwing mechanics, whether a result of poor form or fatigue, will significantly increase the stress the elbow sees during throwing which is why pitch count, conditioning and proper mechanics are important.

Did I tear it because of too many curveballs?

The answer to this is still unclear but biomechanical studies have shown that curveballs place less stress on the UCL than fastballs (screwballs place the highest stress on the UCL).  Since the UCL can be thought of as a thin cord that gets pulled and stretched every time a pitcher throws a ball, it’s easy to imagine that, over time, the cord will thin and can ultimately break.  Most athletes have similarly sized UCL’s and therefore, someone who throws 90 MPH will put more cumulative stress on their UCL than someone throwing 70 MPH.  Again, observing pitch counts, using proper mechanics and avoiding stress pitches while fatigued are all controllable factors that can protect the UCL.

Will I have to have surgery?

If an UCL injury is suspected, we will likely order an MRI or an ultrasound.  Partial tears are frequently treatable with rest and therapy along with correction of throwing mechanics.  Occasionally platelet-rich plasma (PRP) injections are recommended for partial tears. In elite non-throwing athletes, even with severe tears, most can return to their normal athletic activities with several months of therapy and bracing.  However, our throwing athletes with significant UCL injuries often require surgery to return to their previous level of pitching.

What is Tommy John surgery?

If nonsurgical options fail to resolve your problem or if the damage is too extensive, surgical treatment may be recommended.  This involves a reconstruction of the ligament typically using tissue from elsewhere in the patient’s body often either the wrist or the knee.  This is then inserted into the elbow to function as a new UCL–this is what is commonly known as “Tommy John” surgery.  The surgery takes just over 60 minutes and is done on an outpatient basis though a 9-12 month period of healing and rehab is required prior to full return to athletics.

In select injuries, a repair of the damaged ligament (as opposed to a reconstruction with alternate tissue) with placement of an internal brace can be performed.  This is a newer technique which Dr. Bak has been performing and can shorten the ultimate return to throwing in appropriate patients. This is appropriate only in acute tears with specific anatomic characteristics with a recovery slightly shorter than formal reconstruction.

Typically return to throwing occurs 6-9 months after surgery but often requires over a year of healing and rehabilitation to return to high-level throwing on a routine basis.  Success rates are quite high for this procedure if time is appropriately invested in your rehab program.  Having trained under New York Yankees team physician, Dr. Christopher Ahmad, Dr. Bak is well-trained and highly experienced in treating these injuries.

Will I throw harder after the surgery?

There is an undercurrent of thought that throwers have increased velocity after TJ surgery, in some cases causing throwers to inquire about the surgery without an injury.  There is no evidence that velocity increases after the surgery.  However, as UCL injuries often develop gradually, there may have been a minor dip in velocity prior to developing symptoms that causes some to erroneously attribute increased velo after returning to the mound to the surgery rather than the fact they are throwing with a healthy elbow again.  Also, the focus on rehab and mechanics during recovery likely has more to do with improved velocity as opposed to a direct result of UCL surgery.

What is an Elbow Arthroscopy?

Elbow arthroscopy is a minimally invasive procedure useful in treating many painful elbow conditions.  This procedure minimizes scar formation which is particularly important in the elbow due to its inclination to develop stiffness after injury or surgery.  3 to 5 small incisions are made around the elbow and a pencil-sized camera is inserted to diagnose and treat conditions within the joint.

Why would I need an Elbow “Scope”?

Cartilage injuries, bone fragments and bone spurs can be removed using this advanced technique.  Likewise, arthritis and tendonitis are often treated with “the scope” leading to rapid improvement of an otherwise chronically painful joint.  Certain fractures can be treated arthroscopically and one of the most beneficial procedures is removal of spurs in our “more experienced” overhead athletes who wish to continue throwing.  The elbow is notorious for scarring and stiffness after surgery; elbow arthroscopy has been quite successful in minimizing this problem that occurs after traditional open surgery.

What happens during the surgery and what should I expect after?

This is an outpatient procedure during which a fiber optic HD camera is inserted into the joint and specialized instruments allow for repair of cartilage and tendons as well as removal of diseased tissue. The elbow will remain swollen for several days after the surgery and may drain for several days.  While post-surgical course depends on the specific procedure performed, typically very little immobilization is required after this procedure although a generous amount of physical therapy is often necessary.  

Drs. Frush, Bak and Silas have extensive experience with arthroscopic treatment of elbow injuries, including complex allograft (donor) reconstructions of elbow joints using arthroscopic techniques.

How do I know I have a Distal Biceps Tear?

Biceps tendon injuries at the elbow occur with lifting heavy objects, more specifically, losing the grip on a heavy object while trying to keep it up.  The tendon usually ruptures when the elbow is losing its “bend” and straightening out as you’re trying to hold something up with the elbow flexed.  Sudden onset of pain in the elbow and forearm often (but not always) coupled with an audible or palpable pop. Within several days bruising develops along the elbow and forearm although the arm remains relatively usable for lighter activities.

How is a distal tear different from a biceps tear at the shoulder?

Distal injuries differ from a biceps injury at the proximal (shoulder) end of the biceps.  Biceps tendon injuries at the shoulder are not as critical as those at the elbow.  Frequently the biceps injuries at the shoulder can be treated nonsurgically or, if surgery is necessary, on a delayed or elective basis.  On the other hand, loss of the biceps at the elbow can lead to significant loss of strength.  The weakness occurs not just with bending at the elbow but also with turning the forearm and palm upwards (think right hand tightening a screw or left hand loosening a screw).  These are also time-sensitive and ideally are repaired within 2-3 weeks of injury for best results.

What is the treatment?

For active individuals, surgical repair of the biceps is recommended since nonsurgical treatment leads to a significant loss of strength.  In certain sedentary people, particularly in the nondominant arm, nonsurgical treatment can be an option as long as the patient understands that some permanent loss of strength will occur.  If the tear is not treated and is beyond 6 weeks from the injury, often a donor graft is required to lengthen the damaged tendon and complete return of strength is more unpredictable.

What type of surgery is performed?

Surgical repair of distal biceps tendon ruptures is an outpatient procedure which takes 45 minutes to an hour to perform.  The tendon is about the size and shape of a USB plug and runs along the front of the elbow before diving deep into the forearm, where it attaches to the radius bone.  Reattachment involves a combination of sutures, tunnels in the bony attachment site and occasionally a metal anchoring device. Recovery involves several days of immobilization followed by gradual resumption of light daily activities with the affected arm as well as physical therapy.  This is a very successful procedure in which most people can return to normal daily activities within several weeks.  However, return to vigorous activities, sports and weightlifting may take 3-4 months.  Recurrent ruptures are quite rare, in fact, it is more likely that the opposite biceps tendon will sustain an injury as opposed to the repaired biceps.

Drs. Bak and Silas have performed several hundred successful biceps repairs and do this on an outpatient basis.  They also have performed multiple reconstructions of the distal biceps using donor ligaments in situations where the patient has had the injury for several months which can make a primary repair unlikely.

What Is Tennis Elbow?

Tennis elbow is a disease process that results in the degeneration of the tendons that attach to the outside (lateral) aspect of the elbow. These tendons attach to the muscles that extend your wrist. Tennis elbow is typically caused by overuse activities such as repetitive gripping and heavy lifting.

What Are The Symptoms?

Pain is located on the outside of your elbow. The pain may radiate into your forearm. The symptoms may worsen with heavy lifting and grasping/gripping objects. This most commonly affects the non-dominant arm during backhands in tennis and the non-dominant arm in golf. 

How Is It Treated?

The majority of patients with tennis elbow will get better with conservative treatments but it may take a few months for the symptoms to resolve. It is important to follow the prescribed treatment plan recommended by your physician. Each treatment plan is individualized and may include the following:

• Activity Modification/Rest
• Ice 
• Over the counter medications such as Ibuprofen, Aleve or Tylenol 
• Tennis elbow strap
• PRP injection
• Cortisone injection
• Physical therapy 

When Is Surgery Recommended? 

Surgery is indicated when all conservative treatments have failed and pain continues to interfere with activity. The two surgical options for tennis elbow are TENEX procedure or outpatient mini-open procedure which takes approximately 30 minutes. Drs. Silas, Bak and Moore treat this regularly and will determine which option is best for you.

What Is Golfer’s Elbow?

Golfer’s elbow is a disease process that results in the degeneration of the tendons that attach to the inside (medial) aspect of the elbow. These tendons attach to the muscles that flex your wrist. Golfer’s elbow is typically caused by overuse activities such as repetitive gripping and heavy lifting.

What Are The Symptoms?

Pain is located on the inside of your elbow. The pain may radiate into your forearm. The symptoms may worsen with heavy lifting and grasping/gripping objects. With golf, this most commonly occurs in the dominant elbow.

How Is It Treated?

The majority of patients with golfer’s elbow will get better with conservative treatments but it may take a few months for the symptoms to resolve. It is important to follow the prescribed treatment plan recommended by your physician. Each treatment plan is individualized and may include the following:

• Activity modification/Rest
• Ice 
• Over the counter medications such as Ibuprofen, Aleve or Tylenol 
• Golfer’s elbow strap
• Cortisone injection
• PRP Injection
• Physical therapy 

When Is Surgery Recommended? 

Surgery is indicated when all conservative treatments have failed and pain continues to interfere with activity. Surgical options for golfer’s elbow include the TENEX procedure and outpatient mini-open repair which requires about 30 minutes.  Drs. Silas, Bak and Moore all treat this problem regularly and can guide your treatment toward the least invasive and most effective option for you.

What is Cubital Tunnel Syndrome?

Cubital Tunnel Syndrome is a condition in which the ulnar nerve (also known as the “funny bone”) becomes compressed at the elbow.  While this can occasionally occur due to direct trauma, this is more commonly a gradually developing condition.  Symptoms include numbness and, less commonly, pain along the inner part of the forearm extending predominantly into the ring and pinky fingers.  It is typically worse at night and many people also experience this when driving for long periods of time.

Does it require surgery?

Many with this problem will improve with rest, modifications of their work or driving environment (changing the height of your computer chair, ergonomic mouse, altering steering wheel height) and using an elbow splint at night to prevent bending of the elbow during sleep.  Treatment is also partially based on EMG testing which is performed to test the health and degree of compression of the nerve.

What type of surgery corrects Cubital Tunnel Syndrome?

An ulnar nerve transposition is a 45 minute outpatient procedure that moves the nerve from its constricted ulnar tunnel (the funny bone part of the elbow) and into a different position on the elbow less prone to compression.  This requires an open incision on the inner part of the elbow as well as a splint for several weeks.  A short period of therapy is needed but full recovery can take at least 3 months.

Drs. Bak and Silas see and treat this problem frequently.

What is the Lateral Ulnar Collateral Ligament (LUCL)?

Also known as “not the Tommy John ligament”, this is a ligament on the outside part of the elbow.  It is often damaged in elbow dislocations, radial head fractures and otherwise minor falls onto the outstretched palm.

What are the symptoms of LUCL tears?

When associated with dislocations or fractures, general elbow pain is the primary symptom.  However, isolated LUCL tears are often misdiagnosed due to their subtle symptoms.  Mild pain or clicking when pushing off from a chair or performing a push-up can be the primary symptom in isolated LUCL tears.  Another common scenario is clicking or pain after tennis elbow surgery as the LUCL can be inadvertently damaged during these procedures.  MRI and physical exam in the office can usually confirm diagnosis of these injuries.

How are these injuries treated?

Low-grade tears are often treated with physical therapy and bracing.  PRP injections are frequently an important adjunct to nonsurgical management of these injuries once the diagnosis is confirmed.

When is surgery necessary?

In acute injuries associated with fractures or dislocations, these ligaments are often directly repaired during surgery for the associated injuries. In isolated or chronic situations, reconstruction of the ligament using a donor ligament from your wrist or knee may be necessary.  This is an outpatient procedure which takes about 60 minutes.  A splint is worn for several weeks followed by bracing and physical therapy.  Full recovery and return to sports requires 3-4 months.

Dr. Bak is one of the Midwest’s most experienced surgeons for this condition.

What Is A Radial Head Fracture?

The radial head is part of the radius, one of the two bones in the forearm. The radial head is located at the end of the radius that helps to form the elbow joint. A radial head fracture is usually caused by a fall onto an outstretched hand. The force from the fall travels from the hand, through the forearm bones into the elbow. 

What Are The Symptoms?

Common symptoms include pain on the outside of the elbow, swelling and bruising. Many patients will be unable to completely straighten the elbow or rotate the palm up (supination). 

How Is It Treated?

Treatment of radial head fractures is dependent on the complexity of the fracture. Many radial head fractures are simple cracks with minimal displacement and do not require surgery. These types of fractures are treated in a splint or a sling for 1-2 weeks and early elbow range of motion is recommended. 

When Is Surgery Recommended? 

Surgery is recommended for complex fractures when there are several fragments or if there is significant displacement of the fracture. If left alone, these types of fractures will get in the way of the elbow range of motion. The goal of surgery is to restore elbow motion. This can be achieved through a small open incision on the outside of the elbow. The fracture fragments are fixated together using a combination of small metal pins and/or plates and screws. This is called an open reduction internal fixation (ORIF). Other surgical methods include excision of the radial head and radial head arthroplasty (replacement). You and your surgeon will determine the best surgical plan based on the fracture type and activity level. 

Drs. Silas and Bak are highly experienced in both surgical and nonsurgical treatment of these injuries.

What is the Olecranon?

The olecranon is the bony point of your elbow.  It provides the attachment site for your triceps muscle as well as the part of the elbow joint that captures and hinges on the end of the humerus.

How does the Olecranon Fracture?

Typically from a fall directly onto the point of the elbow.  Immediate pain and swelling are noted and movement of the arm, particularly trying to actively straighten the elbow can be quite painful.  Occasionally the elbow can dislocate with this type of fracture which is a complex elbow injury requiring both bony and ligament repair to correct–something the surgeons at MCO are well-versed in.

What is the treatment for an Olecranon Fracture?

If the fracture is not out of place, a cast for several weeks followed by a brace and therapy can produce a fully healed, normal elbow.  In fractures where the joint is disrupted or the fracture ends are separated, a surgical repair is recommended.  This generally involves either wires or a plate/screw construct.  The goal is to anatomically restore the elbow joint and produce a strong enough construct to allow you to come out of a cast or splint within several weeks. This is typically an outpatient procedure.

Full recovery is expected with these fractures, however patients frequently want the plate or wires removed after healing since they are often easy to notice on the point of the elbow.  This is routinely done when desired once the fracture is healed.

Drs. Bak, Frush and Silas routinely treat simple and complex injuries of the olecranon and elbow.