Last night, the news broke out that Miami Marlins starter Jose Fernandez suffered an undisclosed elbow injury that needed serious examination and forced him onto the disabled list. Fernandez had an MRI done in Los Angeles and flew back to south Florida to have a second MRI done to examine the potential damage to his elbow. The signs of injury appeared to have occurred during his latest start versus the San Diego Padres, during which his fastball velocity dropped significantly in his last two innings.
The Marlins have experience handling this sort of potential injury before, but it has been a while since the Fish have had a significant name go through this process. In 2003, A.J. Burnett suffered an UCL tear that cost him the entire World Series season. He came back strong in 2004 and 2005 and went on to have a successful career. Josh Johnson was injured late in his terrific 2006 rookie campaign and lost essentially one and a half years of on-field play before returning to the field with a better velocity.
The recovery from the injury and surgery is different for each and every pitcher, but we here at Fish Stripes have yet to deal with this problem so close to home. So what is the injury at hand that could be causing problems with Fernandez, and what is Tommy John surgery?
The elbow has stabilizing ligaments on either side because it is not designed to move in that direction. The strongest of the two ligaments providing valgus (lateral motion away from body) stability to the elbow is the ulnar collateral ligament, or UCL. This ligament runs originates from the medial epicondyle, the bony part of the elbow joint closest to the body, and runs to the humerus. It consists of three bands, the anterior of which is the most pertinent for preventing valgus stress during the throwing motion.
It is easy to see why the UCL is so stretched and stressed during pitching and throwing. In the throwing motion, the forearm lags behind the upper arm and is restricted in motion by the UCL. Repetitive motion, however, can loosen or damage the ligament and cause instability of the joint. It turns out that motion of the arm during acceleration of the throwing motion causes more force than the tensile strength of the ligament, leading to injury. Furthermore, it has been studied that increase in maximum velocity by pitchers correlates to likelihood of injury and possibly severity of injury.
The type of injury that can be seen in players can range from microscopic damage to acute and full-on tears. For microscopic injury that does not affect the general stability of the joint, the likely presentation is pain caused by inflammatory response of the healing body. Acute small injuries that do not fully damage the ligament are called strains or sprains and work akin to those sorts of injuries to other joints like the ankle. They are acute in nature but are minor, likely a result of acute high stress or due to deterioration of long-standing problems.
The UCL tear is the concern when players have to consider surgery for repair. Most strains can be cared for with rest, ice, compression, and elevation, all aimed at reducing inflammation and not exacerbating the injury. Tears, on the other hand, can cause joint instability. In acute rupture of the ligament, bleeding can case bruising to the area in addition to swelling and pain. Range of motion is not usually affected but can be. Valgus deformity (with the forearm pointing outward while the elbow is at rest) may be possible. Putting stress in that direction can reproduce pain and open the joint.
As mentioned, the most likely presentation is pain, most often chronic because so many of these injuries are exacerbated by consistent repeated throwing motions. The damage can be accumulated over time, meaning that players may recall previous acute episodes of pain. Given the nature of sports culture, it is likely that players underreport these symptoms until they become difficult to bear. In acute tears or strains, there could be a "popping" sensation reported as well.
Tommy John Surgery
For severe cases that involve tears to the ligament, Tommy John surgery may be required. In normal people without the demand of consistent overhand throwing motions, rest and conservative management is possible, as the body can repair the tear on its own. Surgery is only recommended for patients with significant damage who are suffering through chronic, severe pain or athletes whose motions demand more of the ligament.
MRI and, more likely, MR arthrography, is done to assess level of damage and candidacy for the procedure. MR artthrography is the most sensitive modality for spotting injury, as the UCL is small enough for injury to go unseen in regular MRIs.
The surgery itself involves reconstruction of the anterior branch of the UCL. The way it is done is by taking the tendon of another muscle, the relatively functionless palmaris longus muscle, and wrapping the tendon in its proper anatomical locations around the epicondyle and joint in a figure-eight pattern. The ulnar nerve, which controls various hand motions and sensation of the last two digits of the hand, may also be moved to prevent injury and post-operative problems.
From there, players go through rehab and physical therapy. For the first ten days, the arm is splinted still. In one month, the player can utilize isometric exercises involving applying force while remaining still. Throwing should begin in four to six months after surgery to avoid the valgus stress on the arm. Competitive throwing should be the goal at nine to 12 months.
Despite all of this, players may still suffer from instability and pain in the joint, but the success of the procedure is so widespread that complications following it are relatively benign. Pitchers are usually not limited in their work by undue pain following rehab of the procedure. Neuropathy of the ulnar nerve caused by post-operative damage or inflammation can occur if the nerve is not moved; symptoms would include numbness or tingling and weakness of the hand.
Fernandez may yet have a long road to recovery if he indeed is forced to have surgery. It would be a disappointing end to his season if that were the case, but the procedure and injury can be overcome. If this happens, here's hoping Fernandez is better than ever.
Information for this article was garnered from Medscape Reference and Current Diagnosis: Pediatrics, 9th Ed