On this episode of the #AskMikeReinold show we talk about working with Tommy John injuries of the ulnar collateral ligament, and whether or not they can be successfully treated nonoperatively. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 225: Can Tommy John Injuries Avoid Surgery?
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Show Notes
- 8 Keys to Tommy John Rehabilitation
- Understanding Tommy John Surgery and How to Avoid It
- 5 Myths of Tommy John Surgery
Transcript
Mike Reinold:
We have Justin from Miami says, “What’s up guys? Wondering your thoughts and experiences you’ve had with your long term outcomes regarding Tommy John injuries, returning to sport, et cetera, without having surgery, so a non-operative treatment for grade one or grade two UCL sprains. Our clinic specializes in youth to major league baseball players and the research is all over the place, and it’s very little on long-term outcomes. Seems like most of them get back to the sport easy, but we have many repeat offenders. What are your thoughts?”
Mike Reinold:
Let’s see, let’s start this off easy, because he said grade one, grade two UCL sprains. Let’s start this off easy. Dave Tilley, I’m going to call on you. Do you ever see grade one, grade two UCL sprains?
Dave Tilley:
Yes.
Mike Reinold:
You do, really? I guess you do. I was just thinking yours are more… Yours would just blow up in the gymnast environment, like a grade four.
Dave Tilley:
There are some grade 11s. No, we see a few of them because they’re hyperextension overloads, they lock out into hyperextension and it sprains the anterior capsule and the UCL.
Mike Reinold:
Ooh, all right, we’re going to come back to that, because wow, that’s going to be hard to do non-operatively, but we’ll get back to that. The big thing with the UCL that I think we should consider before we get too deep is grade one, two and three. We talked about those real quick before we discuss that. I love the scale by the way. Who came up with this scale?, Let’s do the research on ligament injuries and how we came up with the scale. It’s mild, moderate, freaking torn in half, right? That is our scale system.
Mike Reinold:
It’s not freaking torn in half, so it’s a one or two, which I don’t even know how we really grade those. With a UCL injury, it’s very rare that it’s traumatic, an acute traumatic injury, like it snaps in half. I actually brought Dave up because, in gymnastics, they probably get some more of those, right? Dave, how do they happen in gymnastics? Forced hyperextension usually? Or is it valgus?
Dave Tilley:
Classic FOOSH, people put their arm out when they’re falling on a skill, and it hyper extends the disc. It’s the hardest case, and I can tell the story later which, I’ve never been more thankful for your guys’ mentorship in my life, is when we had the hardest case I ever treated. It was a girl who dislocated and tore both her Tommy Johns. We call them Tammy Jane’s in female. She did them both at the same time, so she literally did a skill, landed on both arms, hyper extended, tore both her UCLS and dislocated both, and then had some nerve issues. I was like, “This is way too much for me as a new grad, I need help.”
Mike Reinold:
Yeah, so we tried non-operative rehab… I’m just kidding, she definitely went to surgery. That one was super easy. Lenny, I think you’re at a big disadvantage for this conversation, right? But, I think you and I are a good tandem for this. You see a lot of injured people. You usually see them when they’re worse off and less like, “Hey, it hurts me a little bit.” They’ve usually got to be pretty flared up to get to see you. What are your experiences in general on this, and what do you think your success rate is for non-operative?
Lenny Macrina:
Yeah, I definitely can recall cases in my head where I’ve had people come in, either after PRP or no PRP, and it was a mild sprain, like a grade one, two, whatever. It’s a very subjective grading, I think, but I’ve had people successfully get back. It’s especially the ones that are in their senior year and are just forcing it. We’ll get one, maybe two years out of it, but I don’t recall that five, six year, “I got back…” It’s usually we’re forcing the situation because of their personal situation. I’d say more likely than not, they need surgery if they are symptomatic on the table because they can’t throw. We look at them on the table and they’re still symptomatic, and there’s a good chance they need surgery.
Lenny Macrina:
Again, I don’t know how the docs determine it on MRI, what they’re looking for in particular. Obviously, they’re looking for a gross blow out, so to speak, where fluid is leaking out of the joint. That probably doesn’t have a good prognosis, but I have had it. Why? I don’t know, maybe… I doubt it was anything in particular I did. There wasn’t anything different that I did, but I think, maybe on exam, somebody presents pain with not all the tests that I do, which is going to be a milking sign, which is going to be a supine force valgus. If they have significant pain with both of those tests, there’s a good chance they’re going to fail non-op treatment like PT, but there is hope. I would say it’s probably, I don’t know, 20% maybe? Something like that, at the most.
Mike Reinold:
Yeah, I think I would agree with you with that percentage too. I wonder if a lot of times, the grade ones that are mild injuries are the people that just have an achy elbow, and they don’t even think anything of it. It’s not injured, injured. It’s more sore. By the time they get in the clinic, it’s almost a grade two. This is going to be our new scale, by the way. Grade one is, it’s not sore enough to come see me. Grade two is, it’s sore enough to see me, and grade three is, it’s torn freaking in half. That’s our scale system. Maybe that’s a big part of it, Len, is because we don’t see a lot of grade ones maybe, but that being said, I don’t know.
Mike Reinold:
I think, over the years, we’ve gotten a little bit more pessimistic with these. Once you start injuring that, it’s such a small amount of stability or instability, I should say, that you need to be dysfunctional to have pain, to start having other symptoms. Your joint gets annoyed, or your ulnar nerve gets flared up, or your flexor mass gets sore, something like that. By the time we start seeing some symptoms, it’s usually pretty tough. I think, going back to Justin’s question here too, is that, oftentimes, we’re prolonging it. I would say, the only people that we do really successful with is the people that we literally get for the first time. Dave and I are co-treating a guy right now that didn’t have pain ever in his life, senior in high school, didn’t have pain ever in his life until two weeks ago, and felt it in one bullpen. I’m like, “Okay, we’ve got a chance here.”
Mike Reinold:
Maybe this was just annoyed, the flexor mass is a little annoyed. There’s actually been studies in the last couple of years published that show that, with some rest, the ulnar collateral ligament does change. Right? It changes with both stress in season and changes without stress in the off season, so maybe we can do well with that person. But once you have significant symptoms, it’s tough. I would say, going back to what Lenny said, one of the big indicators for us is we may still go through that non-operative period, so six weeks without throwing, for example, is probably our big thing. I can usually tell, if I’m confused on day one, it’s usually by week three, I’m not confused anymore. You’re either better or not. It’s very rare that you get to week three, four, you’re still a little sore, but then magically, week five, week six without throwing, you’re better.
Mike Reinold:
Right? That’s a little bit more pessimistic, so we use that as a scale. I think you’re right, Justin, I think there is some pessimism as to how well this works. I think it’s probably because, a lot of times, they come see us when it’s a little bit too far along. Why don’t we focus on what we can do in that six weeks real quick to finish up this podcast episode a little bit, because I think we’re all still going to be faced with that. I talked to Dr. Andrews in January this year, so I still ask him the same questions over and over every year when I bump into him, because I want to know his answers, but we still think the majority of people should go through that non-operative period of six weeks of rehab, because most of them aren’t ready for it.
Mike Reinold:
There are times that their exam on day one looks just bad enough, and the timing of this injury dictates that, “Hey, let’s get this going so we don’t screw up this year and next year.” But, most times, we’re going to do that six week period. During that six weeks… I don’t know, why don’t we do this? Why don’t we say… Lenny, I’d love to hear your thoughts on maybe what’s our brief summary of the rehab plan in the six weeks. Diwesh, what do we do different in the gym, maybe, during those six weeks to really get a good comprehensive program. But, Len, you want to jump in on that?
Lenny Macrina:
Yeah. Obviously, the elbow takes the brunt of the force with throwing. We talk about lay back position and follow through are the two key instances where the most stress is on that anterior band of the UCL. We treat the elbow, but we go definitely to shoulder and scapulothoracic joint. We put some research out that showed that lack of overhead mobility, so flection, may contribute to stress on the elbow, so we have to look at that. Do they have good passive, inactive, overhead mobility? If they don’t, we need to address that, to try to take some stress off that [inaudible 00:10:40] level. Maybe that’s why it got them in trouble. Maybe they were doing something heavy lat dominant, like throwing or anything else that would block their overhead mobility, so we’re going to address that.
Lenny Macrina:
Obviously, we’re going to look at shoulder weakness, we’re going to do some handheld dynamometry isometric testing and see if their ratio of ER to IR is appropriate. We probably want about 65, 70% of a ratio of external rotation, internal rotation, so we’re going to try to tease that out. We’re going to look at total motion, we’re going to look at passive, external and internal rotation bilaterally, and get a total motion, and on bilaterally, hopefully it’s pretty symmetrical. The numbers that make up ER and IR are going to be different. They should have more external rotation on the throwing side than their non throwing side. If not, we got to figure out why. There’s a gazillion scenarios that can contribute to that. We can figure out why and try to address it. We’re going to look at overhead mobility, total range of motion ratio, we’re going to look at strengths and anything else.
Lenny Macrina:
What are they doing in their programs? Do they ramp up their throwing? Did they begin incorporating a weighted ball program, or something strenuous on the shoulder and elbow that may be contributing to this. We’re going to modify it or cut it out. I think those in a nutshell are going to be my big points that I hit in somebody. We’re going to come up with a program, and then we’re going to figure out timeframes of when they need to get back to throwing and count backwards. How much time do we have until you have to throw again in season? Then, figure out a throwing plan and come up with a plan for them, and then just wing it from there, adjusting as needed.
Mike Reinold:
It makes perfect sense. Most of the times, people come to us and it’s not like we do an exam on them, and you’re like, “Wow, you look amazing.
Lenny Macrina:
Right. Yeah.
Mike Reinold:
There’s plenty of things we have to work on. We’re going to clean up their motion. We’re going to clean up their strength deficit, which almost every kid has. I think the biggest thing other than cleaning up their motion and their strength, and then, obviously, it’s workload management. The first workload management is abstaining from throwing, so actually stopping throwing, and taking that six weeks off. Then, trying to figure out what happened in that period of how did they spike? Did they not have enough chronic workload buildup? Did they spike their acute chronic workload ratio? What happened with their throwing program? Did they do too much too soon? Hopefully, these are some of the things that we can do when we get back.
Mike Reinold:
Now, Diwesh, last thing right here for me. Every kid asks me… We finish up our exam, we talk about, “All right, here’s what we’re going to do. Here’s our six week program.” The first thing they always ask is, “Oh, can I still work out?” They’re always surprised when I say, “Yeah, absolutely. You can do everything.” They’re like, “Wait, what?” Part of that’s because I know Diwesh doesn’t do anything stupid, and you can do something stupid, but maybe Diwesh can talk about some of the stupid things you could do with a Tommy John. Yeah, training wise, I hate to say it, but it’s valgus stress that causes this injury, right? We’re not doing a ton of valgus stress, but, Dewey, anything that goes through your head in that six week period that you do different in the gym?
Diwesh Poudyal:
Yeah. To start, the biggest thing for me is honestly, and you mentioned this, is I want to make sure I still have confidence built in the athlete and letting them know that there’s a ton that they can do. We focus a ton on those things so that they’re not bummed out about their elbow, but also bummed out by not being able to work out. For one, it’s instilling a ton of confidence saying, “All right, there’s a ton that we can do in the gym. There’s probably a small percentage of things that we’re not going to do. Some of these things might include stuff like front rack position for a front squat. Obviously, we’re not going to do cleans. A lot of our pitchers don’t do cleans to begin with anyways. Lenny talked about the milking side, right? That’s it right there.
Mike Reinold:
We don’t want to force it with speed and weight.
Diwesh Poudyal:
Right. That’s stuff that we’re avoiding, and then we might even avoid some things, and this we actually do with our general athlete population anyways, because they’re hyper mobile. Tilley mentioned in the gymnasts super aggressive hyperextension. We’re keeping an eye on how we’re coaching people through pushups and things like that that might take them into that gross hyperextension. We’re going to try to cue them out of that, or maybe even not program some of those things where we know that they’re going to default into it. After that, it just becomes a game plan working with the PTs. If I’m working with Lenny, we’re going to talk back and forth about what the next step for the progression is when we start adding in med ball stuff. We’ve probably got to be doing that stuff before we get back into throwing actual baseball. Once you figure out what you want to avoid, build up some of the strength, the rest is just communicating with the PT and figuring out a game plan to get the athlete back in action.
Mike Reinold:
Awesome, it makes sense. I think the only thing I would add probably with that is that, sometimes depending on how bad these injuries are too, you can have a decent little flexor pronator strain that comes with this. Just keep that in mind, too. I think that’ll be a little self-limiting, it’ll be obvious. Sometimes we’re not going heavy grip. I don’t think this six week period is the time to PR your deadlift, right? We’ll get into that down the road, but you can certainly do things. You can hold dumbbells, you can hold bars. That’s okay, but maybe we’re not pushing that in everybody. In this six week period, you have one thing that matters, is getting this thing to heal to try to avoid surgery. Alright, last thing I want to throw in there. Lenny didn’t mention this. Lenny, is there anything you could do to facilitate healing of the ligament?
Lenny Macrina:
Oh no. No, not at all. Yeah, we use modalities, shocking people. We use a class four laser. In our clinic, we use the molecular laser, and we use ultrasound. Yeah. I know
Mike Reinold:
Wow, you use ultrasound? I feel like…
Lenny Macrina:
I go clockwise, and not counter-clockwise, because-
Mike Reinold:
That helps.
Lenny Macrina:
…that’s what you see on social media to make fun of it.
Mike Reinold:
No way.
Lenny Macrina:
Yeah.
Mike Reinold:
That’s not real. Is it?
Lenny Macrina:
No, that’s the joke.
Dave Tilley:
…water in Australia…
Lenny Macrina:
Right, in the Southern hemisphere, you go counter-clockwise when you do an ultrasound. There is research that shows that, in ligaments, it can help the collagen formation, so why not? Right? These kids are looking for something for healing. There is research to show that it does, so I do ultrasound on their ligament, along with laser. That takes eight minutes total, and then I do the rest of the treatment with the stuff I addressed earlier. It’s a small thing. It’s not the only thing I do. They’re not getting heat, ultrasound, a little massage, and then going on their way. I would love that, it probably could help, but there’s definitely more to it. We definitely use modalities, yeah.
Mike Reinold:
I think this is a great example of why we use modalities. Sometimes our PT students come in, especially if they’re big on Instagram, they’ll come in and they start working with, the first week, a non-op Tommy John. We’re like, “All right, hey, let’s do an ultrasound on them,” and they’re taken aback. They’re just like, “Oh, I don’t know how to handle this. I don’t know how to reconcile my beliefs right now with what I’m learning.” They get all bent out of shape. There’re studies on rats and rabbits or whatever, I don’t know what the… On ATFL and MCLs and the knee, it’s like, “Look, we got six weeks to get this kid back into playing baseball. We’re going to do anything we can.”
Mike Reinold:
Our goals, normalize motion, get their strength back, get their total body going in the gym while we facilitate healing of the ligament. I’ll do anything we can to do that while we’re in that no throw period, and then slowly progress them back, and hopefully make adjustments to their workload progression that may have gotten them into this jam. Now, one thing we didn’t talk about was biomechanics, because that’s not us, right? That’s not our world. We send them to the sport coaches for that. Sure, do I look at the kids’ mechanics sometimes, even on video, and just see if there’s anything jumping out? Yes. But then, we’ll send them to, a friend of ours, somebody that we work with, a colleague that we can say, “Hey, he’s got a couple of things that look like they put a little extra stress on his ligament. What can we do?” Hopefully that helps.
Lenny Macrina:
You’d be surprised when you look at it mechanically.
Mike Reinold:
Yeah, they all do.
Lenny Macrina:
It’s like, “No wonder why your elbow hurts. Where did you learn to throw like that?”
Mike Reinold:
Yeah, kids are crazy. Justin, hopefully that helps. I think we share your sentiment that these are often unsuccessful, but maybe, sometimes, there’re some things we can do to make them more successful, so hopefully that helps. If you have a question like this, head to mikereinold.com, click on that podcast link, and be sure to fill out the form. Ask us anything you want. We’ll be answering all your questions in future episodes. Be sure to go to iTunes, Spotify, to subscribe, rate, review, and we’ll see you on the next episode.
