[Elbow injuries are always in the news, so if I lead this preamble with, “Because elbow injuries are in the news lately … “, it’s going to ring a little hollow. That said, Kyuji Fujikawa is having Tommy John surgery today, Arodys Vizcaino recently had calcifications (possibly “bone spurs”) removed from his already surgically-repaired elbow, and Matt Garza is finally over a “stress reaction” in his elbow that cost him the second half of last season. BN’er Steve – who knows quite a bit about sports medicine – volunteered to school us a bit on the nature of the elbow, elbow injuries, and their relationship to baseball.]
Hello all. I’d like to start out by thanking Brett for the opportunity to contribute here at BN. By way of introduction, I should mention that I’m an orthopedic surgeon (or will be very soon, as I’m graduating residency in a couple weeks) who is also a life-long Cubs fan. I grew up in the Chicago suburbs. Like you, I’m not all that stoked that, lately, it seems like “Chicago Cubs” has become synonymous with “elbow injury.” However, there is a lot of misinformation out there, and I thought it would be helpful to write a quick primer on some of the elbow badness that has come our way lately. I hope it helps offer clarity about some of the medical lingo thrown at you from time to time.
We’re going to start by looking at a simple hinge. Nothing special here.
Let’s think about what makes the hinge. There are two parts that rotate in one plane around a central axis. In this hinge, that axis is set by the pin in between the pieces. But, in this hinge, that pin does more than that. Not only does the pin define the axis of motion, it also prevents motion in other planes. For our purposes, think of that kind of unhelpful motion as “wiggle waggle” – like if you tried to bend the hinge from side to side as opposed to up and down.
The human elbow, in a lot of ways, is just like the hinge we have pictured above. One important difference, though: there’s no pin to hold the hinge together. Instead, the elbow has two features that keep the hinge together and moving in the right direction. First, the shapes of the bones allow them to fit together such that stable motion can occur. Second, there are very strong ligaments that prevent the hinge from “wiggle-waggling.”
This picture of the elbow from the side, with the joint bent 90 degrees, shows how nicely the bones fit together:
I’ve labeled the three bones that make up the elbow (humerus, radius, ulna), as well as the portion of the ulna that we’ll talk about coming up – the olecranon process (the curvy part of the bone that cups around the humerus).
Now let’s take a look at another view of the elbow, this one from the back of it with joint fully straightened out:
You might notice how the whole construct looks a touch shaky from this vantage point. And you’re right. If all there was to the elbow was the bones, there would be a ton of abnormal side-to-side motion. This is where those strong ligaments come into play. Let’s look at that picture again, but this time with two of the main stabilizing ligaments drawn in:
From this picture, hopefully you can see how the LCL (lateral collateral ligament) and UCL (ulnar collateral ligament) prevent “wiggle waggle.” They actually get tight and stop the bones from moving in the wrong direction relative to each other. These ligaments are incredibly strong, which is why it is very uncommon for the average person to have any problems with them.
So what’s the deal with pitchers, then?
It turns out that the act of pitching creates an incredible torque along the UCL, which runs along the inner part of the elbow. You can probably sense it yourself if you do a strong throwing motion. Over time, the repeated stress can negatively affect the ligament and surrounding bones, resulting in any of several conditions.
First, the ligament can actually loosen a tiny bit, much like a rubber band that’s been stretched out too many times. Once this happens, you know that “wiggle waggle” we talked about? It starts happening. The olecranon actually starts rocking abnormally against the humerus during the throwing motion. When that happens, the bone responds by creating bony overgrowths in the area, which can eventually become painful and restrict movement. This condition, my friends, is the infamous “bone spurs” you’ve read so much about. The treatment for this is typically arthroscopic excision of the spurs, which is the treatment Arodys Vizcaino received for his calcification/bone spur issue. (Not all calcifications amount to “bone spurs,” but frequently they do.) Sometimes the pitcher will be fine after this. If the ligament is still intact and strong overall, there may not be any major structural issues in the future. The bone spurs can (and many times do) recur, because that abnormal motion is still happening. But the pitcher can continue to pitch without major surgery. He will, however, try to have his throwing mechanics optimized to minimize the stress on the area going forward.
Sometimes, the abnormal motion actually causes a stress fracture to occur in the olecranon. A stress fracture means there are many microscopic cracks in the bone itself that cause pain. When this happens, the pitcher needs to rest to allow the fracture to heal. Rehab follows resolution of pain. (A “stress reaction,” like that suffered by Matt Garza last year, is sometimes a precursor to a stress fracture, though it’s an ambiguous enough term that his situation may not be strictly applicable here.)
Another thing that can happen as a result of pitching is that the UCL can rupture, or tear. This can occur even if the pitcher has never had any problems with the ligament in the past. When this happens, the pitcher will require surgery if he wants to pitch competitively again. This is because the ligament heals loosely with scar, which is not as strong or as tight as the original structure. The surgeon can’t use the original ligament in the repair; a tendon graft is used to replace it. This surgery is known as an ulnar collateral ligament reconstruction, or Tommy John surgery for short. That’s what Kyuji Fujikawa is having done today, and what Scott Baker (and Arodys Vizcaino) is slowly working his way back from.
You’ve all read about the extensive rehab that happens after this surgery, so there’s no need for me to belabor it here. Suffice it to say, it’s a very intensive process that is geared towards progressively strengthening the elbow while fine-tuning the pitcher’s mechanics. In general, the outcomes after this surgery tend be very good. So keep your fingers crossed for all of our pitchers who’ve undergone the procedure. We need them back and healthy, no doubt about that.
I hope this article shed some light on these elbow conditions and helped you better understand them. Thanks for reading, everyone.
(Pictures via Wikipedia, with visual edits.)