The Ulnar (Medial) Collateral Ligament - Tommy John Surgery
Starring Richard Sherman
UPDATE: Sherman will opt for conservative measures and rehab, for now, instead of surgery per SB Nation.
Last week, I raved about the exciting 2015 NFC Championship game finish between the Seattle Seahawks and Green Bay Packers. But, your 2014-2015 NFL experience would not be complete if you missed the Super Bowl last Sunday. After a ridiculously miraculous Jermaine Kearse catch, the Seahawks looked like they were destined for back-to-back championships. However, unheralded Patriots safety, Malcolm Butler, had other plans and picked off Russell Wilson’s pass at the 45th second mark in their own one-yard line to bring Super Bowl XLIX to an abrupt end. The 28-24 Patriots victory was chock-full of storylines: Pete Carroll’s decision to pass on the two-yard line instead of handing the ball off to BeastMode; Bill Belichick’s choice to withhold a timeout and let the clock tick below the minute mark with the Seahawks inches away from taking the lead; Chris Matthews’ heroic 109 yards, 1 TD performance only months after jumping out of his Foot Locker day job; “Deflate Gate”; Tom Brady’s 4th Super Bowl win.
Buried under the pile of headlines was the injury status of the Seattle Seahawks’ Legion of Boom. Even more criminal is the absence of debate of who was the best cornerback in the NFL between Richard Sherman and Darrelle Revis. The injury that Sherman sustained in the NFC Championship game may have averted such comparisons for another time. As James Starks raced down the right sideline, Sherman and “Bam Bam” Kam Chancellor converged to maul Starks out of bounds. It seemed like a routine tackle, but Sherman was visibly in pain as he picked himself up, favoring his left elbow. Instead of calling it a night, Sherman stayed in the game and kept his elbow in a bent position as if it was in an invisible sling. After the inspiring performance, an MRI indicated a sprained elbow, which Sherman played through again after two weeks of rest. Once the confetti has settled, Coach Pete Carroll told the media that Sherman may have suffered ulnar nerve damage and may need Tommy John surgery to repair the ulnar collateral ligaments (UCL).
Elbow pain may be caused by damage to the joint or it surrounding structures. The elbow joint most resembles the hinge model, which consists of the humerus (bone of upper arm), ulna (larger bone of lower arm), and radius (smaller bone of lower arm). Surrounding structures of the joint include:
Epicondyles (medial and lateral) – Bony prominences on the sides of your elbow. Origin of most tendons of muscles that flex and extend the wrist. Most common source of pain.
Olecranon bursa – the hard part of your elbow.
Radial and Ulnar nerves – courses through the elbow joint. May cause pain when pinched as a result of trauma or repetitive elbow flexions.
Biceps and Triceps – controls arm flexion and extension.
Radiohumeral and proximal radioulnar articulation – located below the elbow joint and play a role in palm rotation. Biceps muscles supinate (palm face up) while the pronator teres pronates (palm face downward).
Sherman’s sprained elbow is the result of a ligament strain that is seen most often in throwing athletes. The UCL is part of the network of ligaments that support the elbow. Tears in the UCL may occur when there is an acute, traumatic injury to the elbow resulting from a fall on an outstretched arm or a twist on a planted hand. Research on throwers with ruptured UCLs found that 50% had a single catastrophic event while the other half had symptoms before the event itself (Jobe et al., 1986). The cumulative effect of repetitive throwing may chip away at the ligament because the force generated during the cocking and acceleration phases of throwing causes valgus stress on the elbow (Behr & Altchek, 1997). When the arm is fully extended, valgus stability is divided equally among the medial collateral ligament, anterior capsule, and bony articulation. When the elbow is flexed 90 degrees, the anterior capsule’s load is taken up by the medial collateral ligament, which contributes about 55% of the stabilizing contribution to valgus stress. Meanwhile, varus stress is resisted by the anterior capsule (32%), joint articulation (55%) and radial collateral ligament (14%) (Morrey & An, 1983). These studies elucidate that the UCL is under the most stress and subject to injury during the throwing motion.
Tommy John Surgery is the premiere surgical operation for UCL damage. Previously known as ulnar collateral ligament reconstruction surgery, the procedure involves replacing the damaged UCL with a tendon from elsewhere in the body. Donor tendons are usually spliced from the palmaris tendon in the forearm of the same or opposite elbow, patellar tendon from below the knee, or a cadaver (donor). Dr. Frank Jobe, orthopedic surgeon and Los Angeles Dodgers team physician in 1968-2008, performed the first UCL reconstruction surgery procedure and coined the term after the patient of his first case. Tommy John, pitcher for the Dodgers, missed the entire 1975 season rehabbing his arm after going under the knife in 1974. Before the surgery, he had won 124 games. After 1975, Tommy John won 164 games and pitched until he was 46 years old. Dr. Jobe’s Tommy John surgery resurrected Tommy John’s career that included an NL Comeback Player of the Year in 1976 and 2nd place finish in the Cy Young voting of 1997. At the time of Tommy John’s operation, Jobe put his chances at 1 in 100. Today, 83% of throwing athletes who have the procedure will return to previous or high levels of competition in less than 1 year (Cain et al., 2010).
Relevant Players:
Richard Sherman, CB, Seattle Seahawks: When asked about Sherman’s recovery timetable, Pete Carroll joked, “I really don’t think so [it will take a long time], as long as Sherm doesn’t want to become a late-inning reliever.” Organized team activities (OTAs) generally start around June, which will give Sherman a good 6 months to have the surgery and recover. Like Carroll said, the Seahawks are lucky this isn’t Russell Wilson we’re talking about because Sherman’s positional demands don’t require him to make throws downfield. All-Pro defensive end, DeMarcus Ware, had a similar elbow surgery in February 2014 and was able to recover in time for the season. There won’t be any question that Sherman can return with full force, in time for the upcoming season and thrusting himself back in the discussion of who is the best cornerback in the game. The only question that still lingers is if there would have been a different Super Bowl XLIX outcome had the heart (and the mouth) of the Legion of Boom been healthy.
On Deck: Victor Cruz's PCL
In the Hole: Carson Palmer's Nerve
References:
Behr CT, Altchek DW. The elbow. Clin Sports Med 1997; 4:681-704
Cain EL, Andrews JR, Dugas JR, Wilk KE, McMichael CS, Walter JC, Riley RS, Arthur ST. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med 2010; 12:2426-34
Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. AM J Sports Med 1983; 11:315
Jobe FW, Stark H, Lombardo SJ. Reconstruction of the ulnar collateral ligament in athletes. J Bone Joint Surg Am 1986; 68:1158
