Red Sox pitcher, John Lackey, will undergo Tommy John surgery.  What is this and what does it mean for his career?

ANATOMY

The elbow is a hinged joint, with many structural supports on the inner and outer parts of the joint.  Three bones make up the elbow joint:  the humerus (upper arm bone), the ulna (a forearm bone), and the radius (another forearm bone).

On the inner aspect of the elbow, the medial or ulnar collateral ligament (UCL), gives stability to the elbow.  On the outer part of the elbow, the lateral or radial collateral ligament (RCL) and annular ligament provide stability for the elbow.  A lot of stress and force passes through these structures with certain activities.  The  UCL must withstand a lot of force with pitching.  The motion of pitching produces forces which try to separate the ulna  from the humerus.  The UCL prevents these bones from moving apart.

In addition to these ligaments, the muscles of the tendons that bend and flex the wrist attach to the humerus on the inner part of the elbow.  The muscle attachment to the bone can be stressed with repetitive, high energy motions and forces.

CAUSES

Injury to the elbow is common in pitchers.  The repetitive motions, stresses, and forces that go through the structures of the elbow place it at risk for injury.  The common injuries to the elbow that happens in the adult pitcher include a strain or tear of the UCL, inflammation and degeneration of the attachment site of the wrist flexors (medial epicondylitis), or an osteochondral defect (OCD) of the elbow joint surface. An OCD is where a chunk of bone and cartilage are divoted out of the joint, similar to a pothole in a road.

SYMPTOMS

Most pitchers with thrower's elbow will experience pain and swelling on the inner part of the elbow.  At times there is also loss of strength and pitching velocity.  There will be tenderness and pain over the UCL or the attachment site of the wrist flexors.  If the UCL is torn, these players will also feel instability in the elbow with throwing activities.  If there is an OCD, players may describe locking or catching of the elbow joint. 

TREATMENTS

Treatments are tailored the structure that is injured.  A pitch count is used in baseball to minimize fatigue and stress to these elbow structures.

UCL strain - These players can be treated with rest and anti-inflammatories. Changing the mechanics of throwing can minimize future injury to the UCL.  Physical therapy is used to strengthen and stretch the muscles on the inner side of the elbow.

UCL tear - These players will require what has become known as Tommy John Surgery.  This surgery is a reconstruction of the UCL.  This restores the stability of the elbow.

Medial epicondylitis - This can be treated initially with rest, anti-inflammatories, straps, and physical therapy.  At times, a steroid injection can help calm down the pain.  If an individual fails these conservative options, then surgery is needed to remove the painful tissues and reattach the tendon to the bone.

OCD - An OCD usually develops on the outer aspect of the elbow.  An elbow arthroscopy can be used to remove the loose cartilage and bone.  Since the human body is unable to regrow cartilage, the OCD lesion is cleaned and drilled to stimulate scar tissue to fill in the "pothole.".  

WHEN TO SEEK MEDICAL CARE

Pitchers who have persistent pain, swelling, or difficultly pitching should seek medical attention.

RETURN TO ACTIVITIES/OUTCOMES

Most athletes with a tear of the UCL will need surgery to have a chance at getting back to playing competitive sports.  Recovery will be prolonged and extensive requiring months of physical therapy.  Lackey will likely be throwing again 6 – 8 months after his surgery.  However, most athletes with this injury struggle to return to their pre-injury form.  He will likely miss the entire 2012 season.

VIDEO/ANIMATION

All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Boston Red Sox designated hitter David Ortiz has been seen walking in a boot.  He is out of the line-up, being diagnosed with Achilles bursitis.  Most have heard about Achilles tendonitis, but what is the story of Achilles bursitis.

ANATOMY

The Achilles tendon is the longest, strongest, and largest tendon of the human body.  It runs from the back of the knee to the back of the heel bone.  It inserts into the heel bone (also known as the calcaneus).  The insertion is over an area estimated to be roughly 2cm x 3cm.  Between the Achilles tendon and the heel bone is a fluid filled sac known as the retrocalcaneal bursa.  This sac serves the purpose of cushioning the tendon against the bone and minimizing the irritation to the tendon and. providing some sensation feedback to the foot and ankle region.

CAUSES

A retrocalcaneal bursa can become inflamed for a number of reasons.  A tight Achilles tendon can rub on the bone and lead to inflammation of the bursa.  A bump in the back of the heel bone, known as a Halgund’s deformity or “pump bump” can irritate the bursa and the tendon and lead to bursitis as well.  If the tendonitis and bursitis have been present for a long period of time, the inner part of the Achilles tendon can degenerate and lead to “tendinosis.”  Furthermore, irritation of the tendon for a long period of time can cause calcium to be deposited into the tendon.

This entity is usually seen in females, over the age of 40, and obese.  However, it can be seen in any individual.

SYMPTOMS

Individuals usually experience pain in the back part of the heel.  Swelling may be present.  A bump in the Achilles insertion site may also be present.  The pain is usually worsened with shoes with a back on it, activities that require the ankle to be flexed upwards (such as when you walk up a hill), or movement of the ankle in any plane of motion.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an Achilles bursitis, you should seek medical attention within 1-2 weeks, particularly if the pain worsens or does not improve. A physical exam and x-rays will be initially used to assess your condition.  At times, and MRI may also be needed to look for any Achilles tendon involvement.

TREATMENT

Treatment is initially managed with non-surgical options.  These include the short term use of heel lifts, boots, anti-inflammatories (pills or topical creams), physical therapy to stretch the Achilles, night splints used to hold the Achilles stretched out at night.  Ultrasound, shock wave therapy, platelet rich protein, and laser therapy have had mixed results in the medical literature.  Steroid injections should be used with caution, as the steroid can  lead to the Achilles being torn.

If nonsurgical treatments fail for 3 to 6 months, surgical options are explored.  These include shaving the Haglund’s deformity, cleaning the Achilles tendon (if there is degeneration of the tendon), and tendon transfers (if the Achilles tendon is severely involved).  Depending on the severity of the condition, these surgeries can be performed endoscopically with two small incisions and a camera and tools, or with open surgery.

OUTCOMES

Most patients  with a retrocalcaneal bursitis do well with conservative care.  Those who require surgery will recover for up to 1 year and require a lot of physical therapy.

RETURN TO ACTIVITIES

Depending on the severity of the bursitis, Ortiz may be out of play for 1-4 weeks.

VIDEO/ANIMATIONS

A live surgical video can be seen at: 

PART 1: http://www.youtube.com/NCOCatDuke#p/u/13/S_1ur94eXTk

PART 2: http://www.youtube.com/NCOCatDuke#p/u/5/1quCnfbf6Po

 Animated video can be seen below:

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics