Guest Post: A Primer on Elbow Woes – Bone Spurs, Stress Fractures and Tommy John Surgery

[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:

Elbow posterior ligaments

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.)

Brett Taylor is the editor and lead writer at Bleacher Nation, and can also be found as Bleacher Nation on Twitter and on Facebook.

38 responses to “Guest Post: A Primer on Elbow Woes – Bone Spurs, Stress Fractures and Tommy John Surgery”

  1. King Jeff

    Written by anonymous?

    1. King Jeff

      Nevermind, nice writeup Steve. Congrats on completing residency.

  2. MoneyBoy

    Steve … Thank you so much for your expertise and contribution!! Congrats on finally making your way through the long hours and good luck to you in the future!!

  3. cjdubbya

    Steve,

    As the spouse of an OB resident, the highest of kudos for making it through an Ortho residency. Very good work here as well in explaining elbow issues so everyone can understand them.

    You have a new fan.

  4. sven-erik312

    How much of these injuries is just due to nature or to poor conditioning coaching on the part of the coaching staff?

    1. Steve

      The simple mechanics of pitching are the biggest culprit in these conditions. Some pitchers’ deliveries may be more prone to this than others. Even a well-conditioned pitcher can have these problems, as it can be difficult to adapt the body to accommodate the stresses.

  5. Featherstone

    Great write-up on the topic. Very informative and helpful. Thank you

  6. Rcleven

    Great job. One question.
    Where does the ligament for the repair come from?
    If it comes from the injured pitchers own body is there a second healing process?

    1. Steve

      The graft for the repair is often a non-essential tendon from the pitcher’s own body. Typically the healing process related to graft harvest is simply healing from the incision, etc. We try not to take a graft that will result in any significant adverse effects on a pitcher’s strength or ability to play.

      If, for whatever reason, a graft from the pitcher’s own body can’t or won’t be obtained, a cadaveric tendon can be used as well.

  7. clark addison

    Thanks, Steve. That’s the best explanation of pitchers’ elbow injuries I’ve seen.

  8. LWeb23

    Thanks for the great read Steve, very clear and concise. However, I’ve got a follow up question for ya. This really focused a lot on the UCL and the variations of UCL injuries. As a former athlete in my younger days, I can visualize how pitching/throwing would have an affect on the UCL. But what about the LCL? Is that a common pitching/baseball injury? Is it as detrimental to a pitcher?

    1. Steve

      LCL injury is not typically associated with pitching. However, it is very frequently injured in elbow fractures or dislocations. Someone is much more likely to hurt their LCL by falling hard on the arm, for example, than by throwing.

  9. OCCubFan

    Thanks so much Steve.

  10. Trueblue

    This was great Steve. Thank you for taking the time to share this.

  11. Ron

    This is why i love BN! I get to mix baseball with medicine. Thanks Steve.

  12. Andrew

    Nice writeup Steve! I’ve heard that the surgeon just gets the UCL tendon from the other elbow, is that right? If so how do people undergo multiple Tommy John Surgeries? are there negative effects to the non throwing elbow that would theoretically effect non throwing activities?

    1. Steve

      It turns out the other elbow is not a source of the graft. Typically, the tendon graft is taken from the same arm, if possible, from the tendon of a small non-essential muscle. If that is unavailable, a tendon from one of the legs can be used.

      It’s a little confusing, because a tendon and a ligament are two different things. Ligament runs from bone to bone (usually). Tendon runs from muscle to bone. Although it might sound strange, we use a tendon to replace the torn ligament. It ends up working just fine.

  13. Josh Ed.

    Great stuff, Steve–thanks for the information!

    And thanks Brett for crowd-sourcing on this site: the community benefits from the knowledge sharing. Love it.

  14. Jim

    Fantastic.

  15. Rich

    great write up.. wondering if you have studies on the effects of PRP grafting ( a form of prolo therapy ) if a tear is non-surgical…

    thanks…

    1. Steve

      The data on PRP in general is very inconclusive at this point. Tough to say whether it helps long term in ligament injuries.

  16. Rudy

    “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.”

    Steve, I think this is what probably has happened to my elbow. I used to play and would frequelntly pitch over 100 pitches (with a lot of curveballs) in amateur leagues in my early 20′s. I still play now that I’m in my 30′s but I had stopped pitching as much at first and completely the last 3-4 years. Now my team has been really short and I’ve had to start a couple games. I take a bunch of advil before I throw and it feels fine during but for the next 5 days or so it feels like it’s going to fall off. This doesn’t seem normal and I suspected something was wrong back in my mid 20s but it never really affected me in my day to day life.

    The pain is the worst right where the UCL is. Do you think it’s probably a tear? If so, is there any point in spending the $$ to get it checked out/fixed. I mean I have no illusions of becoming a pro pitcher, lol, with my mid to high 70s lefty FB.

    1. Steve

      Hi Rudy. It’s possible you may have something wrong with your UCL, but there’s a lot of other conditions that can cause pain in that area. If you find that it limits you enough, it might be worth getting it checked out. An orthopedist would need to examine your elbow and possibly order xrays/MRI to fully evaluate you. It’s really tough to figure out a diagnosis without those aspects. Hope this helps!

      1. Crockett

        If I might add – you might have bone spurs in the elbow as well. A lot of patients I see have bone spurs and their pain is not with activity, but 3-5 days post-activity.

  17. August

    Great article, Steve! Shoulders are next?

    1. DarthHater

      I think a column on rock shoulders would be appropriate. Sounds painful.

  18. Internet Random

    “I thought it would be helpful to write a quick primer . . . .”

    When used this way, “primer” is pronounced so that it rhymes with “simmer”.

    I recommend that all you students stand up and laugh in your professors’ faces whenever they mispronounce it. Call them dumb-asses in front of the class and ask them how their students are supposed to trust anything they say if they can’t even pronounce a simple word like “primer”.

    Nice article, btw.

  19. Crockett

    As a PA who has worked in orthopedics for almost a decade, this is one of the best write-ups on baseball-specific injuries I’ve ever seen. Thank you for writing this!

    1. Die hard

      In your practice do you notice that bicep tears are more common among pitchers who lift weights?

      1. Crockett

        My days of working with sports medicine-specific patients are long gone, but I do not remember a correlation between stronger biceps and more throwing injuries. I found that most throwing injuries (especially shoulders) were from chronic overuse or consistently failing to warm up properly. The shoulder joint takes a while to become fully limber.

  20. Die hard

    Pitching overhand is most unnatural movement in sports … Submarine pitchers like Ted Abernathy have less chance of injury.. But too macho to do so– if encouraged at little league level would lose stigma

    1. mudge

      Bring in the women softball hurlers. You want to bring out the crowds, cross the gender line.

    2. DarthHater

      8625324925_e83150df2e_o.jpg

  21. Rich

    Steve thanks
    I have used PRP grafting for hamstring tendon tear at ischial tub
    And it worked really well
    I am a chiro and we added prolo service with a
    My md friend and had good success
    We don’t do it at my office anymore
    Thanks for the input and congrats to you
    Well deserved

  22. Bea Arthur's husband.

    Steve,

    Great stuff. You have a future kid.

    Any educated guesses on why the Cubs are having such a rotten time with these injuries
    And why their strategy of signing rehabbed guys seems to be such a failure.

    Theo always speaks of the 95% success rate. Earlier Cubs pitchers have come back successfully. Kerry Wood as one.

    Maybe it’s just the Cubs. That is sometimes all it is.

    And congrats again!

  23. Bea Arthur's husband.

    Ps-good to see a doctor rather than Will Caroll (who is sharp but no doctor) writing!!

  24. Dougy D

    Nicely done

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