Tommy John Surgery

Tommy John surgery, also known as ulnar collateral ligament (UCL) reconstruction, is a procedure to repair a torn ligament inside the elbow. It is most commonly performed on athletes who engage in repetitive overhead throwing motions, such as baseball pitchers. The surgery involves replacing the damaged ligament with a healthy tendon taken from another part of the patient's body or from a donor.

What is Tommy John Surgery?

Tommy John surgery is a procedure to reconstruct the ulnar collateral ligament (UCL) in the elbow, which is a key ligament that stabilizes the inner side of the elbow joint. During the surgery, a surgeon replaces the torn UCL with a healthy tendon graft, typically taken from another part of the patient's body, such as the forearm, hamstring, or foot. This procedure helps restore stability and function to the elbow.

The ulnar collateral ligament (UCL) is a strong band of tissue connecting the upper arm bone (humerus) to one of the forearm bones (ulna). It is crucial for stabilizing the elbow, especially during throwing motions. When this ligament is severely torn or stretched, it can cause pain, instability, and a significant loss of throwing velocity or accuracy. The surgery is named after former Major League Baseball pitcher Tommy John, who was the first professional athlete to undergo the procedure in 1974. Since then, it has become a common and often successful treatment for athletes with UCL injuries. The goal is to allow them to return to their previous level of athletic performance.

Why it's done

Tommy John surgery is primarily performed to treat a torn ulnar collateral ligament (UCL) in the elbow, especially when non-surgical treatments have failed or for athletes who need to return to high-level overhead throwing. The injury often results from repetitive stress and powerful valgus (outward bending) forces on the elbow, common in sports like baseball, javelin throwing, and tennis. It helps restore stability and reduce pain.

The ulnar collateral ligament can tear gradually over time due to overuse, or it can rupture suddenly from a single traumatic event. Athletes who perform repetitive overhead motions, such as baseball pitchers, are at high risk because these actions place extreme stress on the UCL. This stress can lead to micro-tears that accumulate, eventually causing a full tear. Symptoms of a torn UCL often include sudden pain on the inside of the elbow during throwing, a popping sensation, and a decrease in throwing velocity or control. Non-surgical treatments, such as rest, ice, anti-inflammatory medications, and physical therapy, are often tried first. However, for athletes who need to return to competitive overhead throwing, surgery is frequently recommended to restore the necessary strength and stability.

How to prepare

Preparing for Tommy John surgery involves several steps to ensure you are ready for the procedure and recovery. You will have a thorough medical evaluation, including imaging tests like an MRI, to confirm the diagnosis and plan the surgery. Your surgeon will discuss the procedure, potential risks, and recovery expectations with you. It is important to disclose all medications, supplements, and any smoking habits.

Before surgery, your doctor will review your medical history and perform a physical exam. Imaging tests, such as an MRI (magnetic resonance imaging), are typically used to assess the extent of the UCL injury and identify any other related issues in the elbow joint. You should openly discuss any allergies, existing medical conditions, and all prescription and over-the-counter medications, including herbal supplements, with your healthcare team. Your doctor may advise you to stop taking certain medications, like blood thinners, for a period before surgery to reduce the risk of bleeding. If you smoke, you will likely be advised to stop, as smoking can impair healing and increase the risk of complications. You should also arrange for someone to drive you home after the surgery and help you during the initial recovery period.

What happens during

Tommy John surgery is typically performed under general anesthesia, meaning you will be asleep during the procedure. The surgeon makes an incision on the inside of your elbow to access the damaged ulnar collateral ligament (UCL). The torn ligament is then replaced with a tendon graft, which is carefully woven through tunnels drilled into the bones of your upper arm and forearm and secured in place. The incision is then closed.

Once you are under general anesthesia, the surgeon will make an incision, usually about 3 to 4 inches long, on the inner side of your elbow. The damaged UCL is identified and removed. A tendon graft, often taken from your own body (autograft) such as from the palmaris longus tendon in the forearm, hamstring, or big toe, or sometimes from a donor (allograft), is prepared. The surgeon then drills small tunnels into the humerus (upper arm bone) and ulna (forearm bone) where the original UCL was attached. The tendon graft is threaded through these tunnels in a figure-eight pattern, mimicking the natural path of the UCL. The graft is then secured tightly with sutures, screws, or buttons to create a strong new ligament. After the new ligament is in place and stable, the incision is closed with stitches, and a sterile dressing is applied, often followed by a splint or brace to immobilize the elbow.

Recovery & timeline

Recovery from Tommy John surgery is a lengthy process, typically taking 9 to 12 months, and sometimes longer, especially for athletes returning to competitive throwing. Immediately after surgery, your arm will be immobilized in a splint or brace. Rehabilitation begins soon after, focusing on regaining range of motion, strength, and eventually, sport-specific movements. Adhering strictly to a physical therapy program is crucial for a successful outcome.

The recovery process is divided into several phases. Initially, for about 1 to 2 weeks, your arm will be in a splint to protect the new ligament. During this time, the focus is on managing pain and swelling. After the initial immobilization, you will begin a structured physical therapy program. This program gradually progresses from gentle range-of-motion exercises to strengthening exercises for the elbow, wrist, and shoulder. Around 4 to 6 months post-surgery, if progress is good, athletes may begin a throwing program, starting with light tosses and gradually increasing distance and intensity. This phase is carefully monitored to prevent re-injury. Full return to competitive sports, particularly overhead throwing, usually takes 9 to 12 months, but it can extend to 18 months for some individuals. Consistent adherence to the rehabilitation plan is vital for optimal healing and regaining full function.

Risks & side effects

While Tommy John surgery is generally safe, like any surgical procedure, it carries potential risks and side effects. These can include general surgical risks such as infection, excessive bleeding, or adverse reactions to anesthesia. Specific to this surgery, risks can involve nerve damage, leading to numbness or weakness, stiffness in the elbow, persistent pain, or failure of the tendon graft. Your surgeon will discuss these possibilities with you.

Common surgical risks include infection at the incision site, which may require antibiotics or further treatment. There is also a risk of bleeding or the formation of blood clots. Anesthesia carries its own set of risks, which an anesthesiologist will discuss with you before the procedure. Risks specific to Tommy John surgery include potential damage to the ulnar nerve, which runs close to the surgical area. This can result in numbness, tingling, or weakness in the hand and fingers, though it is often temporary. Other potential complications include persistent elbow stiffness, which might require additional therapy or even another surgery, and chronic pain. In some cases, the tendon graft may fail to heal properly or may re-tear, necessitating revision surgery. While rare, these complications are important to understand before undergoing the procedure.

Success rate

Tommy John surgery has a high success rate, especially for athletes aiming to return to their sport. Studies show that a large majority of athletes, often around 80% to 90%, are able to return to their previous level of competition or higher after undergoing the procedure. However, success depends on many factors, including the severity of the original injury, the patient's adherence to rehabilitation, and the absence of complications.

The success of Tommy John surgery is often measured by an athlete's ability to return to their pre-injury level of play. For professional baseball pitchers, success rates for returning to pitch in a game are frequently reported to be high, with many studies indicating rates upwards of 80%. Some reports suggest that approximately 80% to 90% of athletes successfully return to their sport, with many performing at or above their prior level. It is important to note that while the surgery is highly effective, not everyone returns to their exact previous performance level. Some athletes may experience a slight decrease in velocity or control, even after a successful recovery. The long and rigorous rehabilitation program is a critical component of success, and patients who diligently follow their physical therapy plan tend to have better outcomes. The overall goal is to restore elbow stability and allow for pain-free, high-level activity.

Frequently asked questions

How long does Tommy John surgery take?

The surgical procedure itself typically takes about 60 to 90 minutes to complete. This time includes the preparation of the tendon graft and the reconstruction of the ulnar collateral ligament in the elbow.

Will I have a scar after Tommy John surgery?

Yes, you will have a scar on the inside of your elbow where the incision was made. The length of the scar is typically around 3 to 4 inches. If a tendon graft was taken from another part of your body, you may have an additional smaller scar at that site.

When can I start driving after Tommy John surgery?

You typically cannot drive while your arm is immobilized in a splint or sling, which is usually for the first few weeks. Your doctor will advise you when it is safe to drive, generally once you have regained sufficient range of motion, strength, and are no longer taking strong pain medications that could impair your judgment.

Will I need physical therapy after Tommy John surgery?

Yes, physical therapy is a critical and mandatory part of recovery after Tommy John surgery. A structured rehabilitation program, guided by a physical therapist, is essential for regaining range of motion, strength, and stability in the elbow, and for a successful return to activity.

Can Tommy John surgery be performed on anyone, or just athletes?

While most commonly associated with athletes, Tommy John surgery can be performed on anyone who has a significant tear of the ulnar collateral ligament (UCL) and experiences pain or instability that affects their daily activities or work, and for whom non-surgical treatments have not been effective.

What is the typical age range for Tommy John surgery?

Tommy John surgery is most frequently performed on adolescents and young adults, particularly those involved in competitive overhead sports. However, it can be performed on adults of various ages if they meet the criteria for a torn ulnar collateral ligament and desire to return to activities requiring elbow stability.

Sources

• MedlinePlus — Tommy John Surgery
• Mayo Clinic — Tommy John Surgery
• Cochrane Library — Tommy John Surgery