Injury Breakdown: Strasburg's Predictable Tear
22 year-old Nationals phenom Stephen Strasburg was placed on the disabled list last week for the second time in his brief major league career after suffering what was termed a "significant tear" of the ulnar (medial) collateral ligament (UCL) in his right elbow. He had exited a game early only days before, with what was reportedly flexor tendinitis in his right forearm.
Team officials have been quoted as saying that Strasburg's newest injury likely occurred during one particular pitch. Were the two injuries related? Was the earlier injury a warning sign? For the record, it should be noted that stress to the medial (inner) compartment of the elbow – a common problem for pitchers – can impact not only the UCL, but can also create inflammatory conditions in all of the structures that occupy this region. These include the wrist flexor muscles (which are in the forearm), the forearm pronators (which turn the palm downward), the joint capsule, and the ulnar nerve. The repetitive demands of pitching, and the nature of the motion itself – particularly the phase of acceleration – are generally the primary culprits.
The end result of moderate UCL sprains (Grade II) is laxity (looseness) of the ligaments, which results in joint instability. This instability causes even greater strain on the surrounding tissues. If the offending activity is continued, tissues are prone to inflammation. At worst, they could tear further. Of course, a severe sprain (Grade III) is actually a complete tear of the ligament. These generally occur traumatically, as with one pitch as claimed in Strasburg's case. However, for many, earlier injuries often set the stage. Either way, it is a sad end to Strasburg's rookie campaign.
There are those who didn't require a crystal ball, predicting that Strasburg would have Tommy John surgery lurking in his future's shadow. With youth on his side though, most probably felt he'd buy more time before the injury would hit. Strasburg's unorthodox delivery coupled with the extraordinary pace of his pitches is thought by many to have made his elbow more vulnerable. Let's not forget that Strasburg also missed three weeks earlier this summer with shoulder inflammation. The kid is breaking down. A piece by Bill Conlin details issues with Strasburg's delivery and the possible repercussions that we may be witnessing. If you are interested in more on this topic, take a look.
What exactly is the UCL & what is Tommy John Surgery?
Ligaments attach one bone to another and provide much of the stability at a joint. A partial or complete tear of the ulnar collateral ligament (UCL) of the elbow results in the need for the Tommy John procedure in order to reconstruct this medial ligament. A higher incidence of severe elbow injuries in overhead athletes is partly due to players' increased size and strength as well as the tremendous forces generated, particularly when pitching. More frequent use of the slider and split-finger fastball is thought to be another reason. Advances in medicine have led to an increase in Tommy John surgeries due to better reporting of injuries, an improvement in the ability to diagnose the problem and greater expertise in performing the procedure.
There is a great deal of stress on the inner aspect of the elbow during the throwing motion. A very high velocity (speed) is required to extend (straighten) the elbow, and maximum stress on the inner elbow ligament occurs just after the cocking phase of pitching, when the arm just begins to descend. In fact, at a 90-degree angle, the ulnar collateral ligament provides at least 54% of the stability of the elbow joint (figures from 54% up to 70% have been reported). Acceleration during the throwing motion also places significant stress on the ligament, while compression forces and a high level of muscular activity are also present. You can see why the ulnar collateral is so important and why it is so often damaged.
Normal range of motion for a pitcher's shoulder and elbow is different than that for an average person or even an average player. Likewise, pitchers are much more developed on their dominant side, enabling them to exert with greater force on that side. A UCL tear results in pain and a loss of throwing speed. The instability caused by a tear such as Strasburg's may also result in a stretching (traction) of the ulnar nerve, causing nerve related symptoms. The ulnar nerve is the one you provoke when you hit your "funny bone".
Dr. Frank Jobe pioneered the Tommy John Procedure in 1974. Studies currently show an extremely high success rate, now at about 90%, while the non-surgical success rate of treating a partial tear is about 45-50%. Various studies show that major leaguers generally return to action between 9.8 and 11.2 months post-operatively, though their rehab begins to include a low-level throwing program at about the four-month mark. Even after returning to play however, a pitcher generally is not thought to regain full form for up to two years. As a result, many reports list the return to play in the 12-18 month range.
Strasburg's tender age should help with respect to his ability to heal and return to form. However, it remains to be seen whether his coaches and doctors will encourage him to modify that form in order to protect himself from further injury.
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Abby Sims is an orthopedic and sports physical therapist who has been in private practice in NYC for the past 30 years (you may be familiar with her husband, sportscaster & WFAN alum Dave Sims). Abby has a Masters of Science in Physical Therapy from Duke University and has extensive experience working with professional, collegiate and recreational athletes with musculoskeletal injuries – both non-operative and operative. She has also enjoyed lecturing at many medical conferences. Abby looks forward to responding to your questions or writing about topics that you suggest. For more information about Abby, or her practice, please check out www.RecoveryPT.com as well as www.AthletiSense.com.
