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Ask Dr. Rick – April 2010

April 27, 2010

With spring training beginning and many athletes young and old getting ready to start their baseball seasons, one of the most talked about injuries and surgeries is the Tommy John surgery. This surgery was named after Tommy John, who was a pitcher for the Los Angeles Dodgers. He tore his ulnar collateral ligament and was the first professional athlete to undergo surgery for an ulnar collateral ligament repair in 1974.

This injury occurs when there is an ulnar collateral ligament tear. This is a ligament on the inside part of the elbow. This ligament is very close to the ulnar nerve, which creates sensation to the ring and little fingers. The surgery reconstructs the ligament by taking either a cadaver ligament or a ligament out of the region of the wrist or the knee in order to construct a new ulnar collateral ligament. During this procedure, holes are drilled in the humerus bone of the upper arm as well as the forearm bone to make a new ulnar collateral ligament. This procedure takes approximately 12-18 months of rehabilitation postoperative and is very successful in returning pitchers of all levels to their previous activities.

It is widely felt that poor technique and mistakes in throwing mechanics increase the chance of stress and/or tearing the ulnar collateral ligament. It is also believed that each pitch stresses the ulnar collateral ligament to its maximum and may predispose pitchers to tear the ulnar collateral ligament. Decreasing the stress on the ulnar collateral ligament by not opening up too early and sound throwing mechanics decreases the likelihood of injury or complete tearing of the ligament.

Rehabilitation of an injury to the ligament whether treated surgically or conservatively includes strengthening the elbow, the anterior and posterior shoulder, core muscle structures and generalized mid-trunk strengthening. Although many pitchers have had a Tommy John surgery and returned to participate to the major-league baseball level, there have been a significant numbers of re-tears of reconstructed elbows that have occurred. Pitch counts in young athletes,
good mechanics in adolescent and young athletes, appropriate attention to detail and offseason conditioning, as well as early care and treatment of elbow pain leads to a healthy elbow and can prevent problems with the ulnar collateral ligament and its associated growth plates.

Dr. Rick, my son plays three basketball games a week and has had heel pain that has gotten progressively worse as he continues to play. Do you have any suggestions? Thank you.
– C atherine Droege, Chesterfield, MO

Thank you very much for you question. Generally, when an athlete with open growth plates has heel pain, it is related to Sever’s disease, which is an overload at the growth plate in the calcaneus or heel bone. This is usually progressed and/or worsened with increased activities. The hallmark of treatment includes simple rest and taking a day off in between basketball practices, workouts, etc. If this does not help, orthotics or heel cups, a non-steroidal inflammatory, icing and very gentle stretching have evidenced to improve Sever’s disease. Again, if the symptoms do not resolve with simple rest, the athlete should be seen by his or her physician. X-rays should be obtained to make a specific diagnosis.

Dr. Rick, I am an avid tennis player and have pain in my left knee when I turn to the left. Sometimes walking up and down
stairs seems to bother me and running seems to bother me. Do you have any suggestions?
– Cory Lester, Ladue, MO

Things to be concerned about are iliotibial band tendinitis, patellofemoral maltracking and what is characterized as extensor mechanism knee pain. Extensor mechanism knee pain consists of pain underneath the kneecap or patellar tendon and is due to overload, which is generally attributable to either a tight iliotibial band, weakness in the quadriceps mechanism or malrotation as well as hyperpronation of the foot. If this knee pain does not resolve with icing, short rest and oral anti-inflammatories, a visit to your physician as well as physical therapy would be very helpful. After a physical therapy program has increased your strength and allowed normal biomechanics in the kneecap and quadriceps mechanism, a home program to exercise 2-3 times per week is beneficial to keep this pain from returning. In general, it is very important that this type of anterior knee pain be resolved early and that it does not continue to be problematic, creating chronic, long-term pain and arthritis.

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