What is Tommy John surgery?

Tommy John surgery is another term for ulnar collateral ligament (UCL) reconstruction. It’s a procedure to treat an elbow injury that tends to occur among throwing athletes, such as baseball pitchers. Tommy John was a long-time Major League Baseball pitcher, and he was the first to have this now-common surgery.

Tommy John surgery repairs a torn UCL, a ligament on the inside of your elbow that’s crucial to the stability of the joint. The UCL and the lateral collateral ligament connect the humerus — the long bone in the upper arm — to the ulna, one of the main bones in the forearm.

What are the symptoms?

When the ulnar ligament tears, you may actually hear a “pop.” After that, you may not be able to throw or do much of anything with that arm until it’s treated. Your inner elbow may be sore prior to you actually tearing the ligament. The soreness is due to a strain being placed on the ligament itself.

Other signs of an ulnar collateral ligament tear include:

  • swelling of the inside part of the elbow and the upper forearm
  • a bruise forming at the site of the injury
  • elbow stiffness and an inability to fully straighten your arm
  • tingling in the hand and the little finger and ring finger
  • weak hand grip

Common causes

The stress of repeated throwing motions can cause the fibers in the ulnar ligament to stretch and fray. Over time, small muscle tears (known as microtears) can develop. Eventually, those little injuries take their toll and the ligament ruptures.

Children from the ages of 10 to 18 are experiencing more UCL injuries. The condition is becoming more common as young athletes compete in more games and in longer seasons. Their risk is made more serious because they have an open growth plate in the elbow. It’s called the medial epicondylar physis, also known as little league elbow.

Sometimes falling with your arm outstretched can injure the elbow and cause a UCL tear as well.

What happens during surgery

Before scheduling Tommy John surgery, your doctor may recommend rest and some rehabilitation exercises. These exercises will improve posture, strength, and throwing techniques. Anti-inflammatory medications may also be recommended for pain.

If surgery is needed, however, your doctor may be able to do it arthroscopically. An arthroscope is a special tool that’s fitted with a small fiber-optic television camera. It’s inserted into the elbow through a small incision. The camera sends images to a computer screen, which allows the doctor to see the inside of the joint and the soft tissues (including the ligaments). During arthroscopic surgery, your doctor may be able to smooth out any frayed or rough edges and remove any dead or injured tissue.

A more involved Tommy John procedure requires an open incision. It’s necessary if the ligament has been pulled away from the bone. Instead of repairing the existing but damaged UCL, a tendon taken from elsewhere in the body is used to replace it. The replacement tendon is attached to the bones through holes that are drilled into the humerus and ulna. The tendon is threaded through the holes and held in place with sutures or screws. The replacement tendon usually comes from the hamstring, the forearm, and the foot (big toe extensor tendon).

Recovery timeline

A baseball pitcher could require a year or more of rehabilitation before they’re back in top form. Research shows that in a study of 179 Major League Baseball pitchers who underwent Tommy John surgery, 148 were able to return to pitch in the major leagues again after the operation. Another 26 were able to return to pitch at the minor league level.

Rehabilitating after Tommy John surgery can be divided into three phases. The duration of each phase depends on the individual and the nature of the surgery. If there was more damage to the elbow than just the ligament tear, recovery may take longer. The three phases of rehabilitation include:

  • Phase 1. After surgery, your arm will be placed in a brace. This brace will stabilize your arm at an angle of 60 to 90 degrees. You’ll still be able to do exercises for your biceps, shoulder, and hand. These exercises are important to keep your muscles from atrophying.
  • Phase 2. About two weeks after surgery, you’ll be given the go-ahead to move your elbow joint. The goal of physical therapy at this point is to improve your range of motion. Your arm will still be in a brace of some sort when you’re not using it. The brace could have hinges to keep your elbow stable while you’re exercising the joint. You may also rest your arm in a sling while your elbow continues to heal.
  • Phase 3. After a month or so, your elbow can come out of the brace and you should be able to fully extend your arm. Within a few months, you should regain a full range of motion in your elbow. Physical therapy during this phase will include flexibility and strengthening exercises.

Risks and complications

Tommy John surgery, like other operations, runs the risk of infection or complications due to anesthesia. There is also a low risk of damage to blood vessels or nerves in the elbow. If the ulnar nerve is being irritated as a result of the surgery, it can be moved to another part of the elbow.

Other complications relate to the replacement tendon. The new tendon that’s attached to the bones in the elbow joint may stretch and tear, requiring a second operation. In rare cases, complications develop in the part of the body from which the replacement tendon was harvested. These can usually be treated effectively with medication.

During your recovery, it’s critical that you to pay attention to signs of complications or setbacks, or signs that your elbow isn’t ready for the burden of your sport. Talk with your doctor and trainers about what to be on the alert for after surgery.

Surgical scar

A typical Tommy John surgery requires an incision about 4 inches long on the inside of the elbow. The resulting scar, which forms a “C” when your elbow is bent, will fade somewhat. But it will always be a visible reminder of your operation — and hopefully healthy recovery.

What’s the outlook?

Tommy John surgery can extend an athlete’s career as long as they follow the advice of their healthcare providers. Completing physical therapy is key, as is being patient during recovery. If you accept that the recovery process can’t be rushed, you could be back in action and performing at a high level thanks to this operation named for a high-achieving athlete.