Q: You wrote quite some time ago about a ball player having a bad elbow that required surgical repair. Well, my son is in high school and has had to stop playing ball altogether because of the pain involved. I’m sorry I don’t remember what the name of the problem is but can you please re-write something he can take to his doctor?

A: The name of the procedure is ulnar collateral ligament (UCL) repair a/k/a Tommy John repair., so named after former LA Dodger’s pitcher Tommy John who underwent the first procedure of this type in 1974 – some 40 years ago! The procedure was performed by Dr. Frank Jobe, a LA Dodger’s team physician who passed away this year. With baseball season upon us, it was recently stated that more than 12 major league pitchers, to include Corbin, Johnson and Moore, have already undergone Tommy John surgery which involves ligament replacement with a tendon harvested from another portion of the body – most often from the opposite elbow or forearm of the player’s body. Other potential sites include the thigh, hip, knee, wrist, and other areas. In fact, a 2013 survey showed that 25% of major league pitchers and 15% of minor league pitchers have undergone the procedure. On the downside, the surgery means that a player will be benched for at least a full season, if not longer. The upside of the surgery is that these power players have been found to return to the game throwing as hard and as well as they did prior to the injury. While there is other UCL repair available, the original procedure is still used today.

Interestingly and while most injuries of this sort occur in baseball players, other athletes playing tennis, soccer, football, wrestling, javelin throw, and even gymnastics have been linked to UCL injuries. Symptoms include a decreased ability to throw a ball or other object, a feeling of instability at the site of the elbow, pain, and paresthesias (tingling and numbness) in the fourth and fifth digits.

Prior to surgery, injuries may be managed with a more conservative approach including rest, ice, and over-the-counter NSAIDS (non-steroidal anti-inflammatory drugs), in conjunction with physical therapy to strengthen nearby muscles. It’s when the conservative treatment is ineffective or when the injury is so severe that it demands a more aggressive approach that the Tommy John procedure may be considered. In fact, UCL reconstruction has increased 10-fold in the first decade of the 21st century, according to a May issue in the Journal of Orthopaedic Surgeons.

During the procedure, a tendon is removed from another area of the body (and even from a cadaver in some instances). Surgeons drill tunnels in both the ulna and humerus. The tendon is then passed through the tunnels and woven into a figure eight pattern and any remnants of the original ligament are attached to the tendon. Complications can occur in up to 20% of patients, depending on the technique used, with the most common complication being damage to the ulnar nerve, followed by infection or a hematoma. Rehabilitation is carefully and closely monitored by both the surgeon and physical therapist and may be in a three-phase process. Under ideal circumstances, the first includes wearing an immobilizing splint for up to 10 days; performing gentle range of motion exercises for the wrist, hand and shoulder; wearing a range of motion brace; exercising to strengthen the arm and shoulder; and doing total-body conditioning exercises. Phase II begins approximately six weeks following surgery in which elbow-strengthening exercises are done and for at least four months patients must avoid activities that stress the graft. Phase III begins four or five months post surgery with tossing a ball without any wind-up motion. After six months an easy wind-up may be used. After seven months, a pitcher may return to the mound, and after nine months pitchers may throw competitively IF they are free of pain and have re-gained normal strength and range of motion. Obviously each individual will respond differently but most athletes are in pretty good shape and have that to their advantage. Obviously each individual will respond differently but most athletes are in pretty good shape and have that to their advantage.

So, treatment for what was once considered a game-ending injury and the end of a career for most players has advanced tremendously. Up to 85% of those individuals who undergo the procedure are able to resume at equal to or even above their previous level of competition.

I’m not sure if your son stopped pitching because he was advised by an orthopedic specialist or if a friend recommended he step back. If he has already been seen by a specialist in the medical field, perhaps you might consider making an appointment for him at a tertiary care center for a second opinion since this and every other surgical procedure should not be entered into lightly. Perhaps he simply has over-use syndrome and a few months rest is all that is required. Our bodies are fickle things and we must do what is best in every instance. Stay involved, stay on top of things, but get the professional help necessary to determine how best to approach the situation.