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By Debbie Roberts, LMT

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Spaghetti Elbow: Ulnar Collateral Ligament Reconstruction

Where did the term spaghetti elbow come from? Well, one of the most famous surgeons for pitchers is Dr. James Andrews, the renowned Birmingham, Ala., orthopedic surgeon and founder of the American Sports Medicine Institute. After he performed the surgery on my client / baseball pitcher, the first thing he said to him was, "Your ulnar collateral ligament looked like a piece of spaghetti." There was no integrity left; he was surprised the pitcher had lasted as long as he had before deciding to have surgery.

I was very privileged to be involved for 11 years with this baseball professional, who was a mid-reliever for 16 years. Over the course of those 11 years, I had to grow as a massage therapist to keep up with the task of understanding the multitude of injuries with which he could present.

I decided to write about "spaghetti elbow" for three reasons. The first comes from a recent presentation at a convention, where the question was asked, "What is a Tommy John surgery?" So I thought there just might be more massage therapists out there who could benefit from a deeper understanding of one of the most common elbow surgeries in baseball.

The second reason is being able to share with you how I treated this player after his surgery and helped him get back in the game. And the third reason is I recently had an 11-year-old baseball player in my office with medial elbow pain. So, I am also hopeful that collectively our profession will be able to help not only in the recovery from this surgery, but also in the prevention as well. Understanding the cause and the treatment is important education to the moms, dads, youth athletes and coaches you meet and treat.

What is Tommy John Surgery?

spaghetti elbow - Copyright – Stock Photo / Register Mark Ulnar collateral ligament reconstruction, commonly known as Tommy John surgery, is a surgical procedure to reconstruct the UCL using a tendon from somewhere else in the body. The tendon is used to re-create the damaged ligament and improve the stability of the elbow joint. A tendon is sometimes removed from the patient's wrist and grafted into the elbow – woven in a figure-eight pattern through tunnels drilled in the humerus and ulna bones.

In my client / pitcher's case, the doctor used a tendon from gracilis. Doctors typically complete the operation in about an hour. The surgery requires a full year of rehabilitation and typically another year pitching before returning to pre-injury form. I saw this firsthand with my client / baseball player. Essentially, the body must convert a tendon into a ligament, get it carrying blood again and train it to start working as a ligament. It is very weak immediately after the surgery, and the rebuilding process must be gradual. No amount of therapy can rush this process, so I say this as a precaution to anyone that might think differently.

Dr. Andrews also called Tommy John surgery "the anterior cruciate (surgery) of the elbow" in a USA Today article by Rob Rogacki on May 29, 2014 titled, "Dr. James Andrews Blames Tommy John Epidemic on Pitcher Overuse."

What Contributes to Tommy John Surgery?

I attended a baseball conference in which Dr. Andrews was a speaker, and he made the statement that the valgus stress on the elbow joint is like having a 50 pound bulldog sit on it with each pitch. According to, pitchers with the game's best P/IP (pitches to innings pitched) ratio typically average fewer than 15 pitches per inning. A starting pitcher with those numbers would be able to go seven innings on fewer than 105 pitches.

But take that times the number of appearances over one season, not including practice, and add in how long they have actually played the game – ouch! A mid-reliever's average appearance in a game is one to three innings. My client / pitcher was one of the biggest surprises for the Yankees in 2006, leading the American League with 83 appearances and topping all big-league relievers with 102.5 innings out of the bullpen. Remember, this doesn't include warm-up bullpens, practice, or the fact that they probably started playing at age 5 or 6. No wonder the doctor saw his UCL was spaghetti!

The ASMI states that overuse and muscle fatigue are the biggest risk factors for injury. Often, UCL injuries in pitchers are due to the cumulative damage of thousands upon thousands of pitches thrown, especially if a young pitcher is trying to squeeze every ounce of velocity out of their arm.

As a pitcher's arm fatigues, their mechanics can falter, placing more stress on the ligament in the elbow and shoulder with every pitch. As a massage therapist, you will see and feel a tight pectoralis minor, tight subscapularis, tight posterior cuff, and certainly a tight latissimus, along with biceps and forearm tightness, to name a few.

Tommy John surgery has become an epidemic because of the additional risk factors for adolescent pitchers, which include pitching on multiple teams, pitching year-round, playing catcher when not pitching, poor pitching mechanics, and poor physical conditioning. Another factor is the lack of conditioning education of the adolescent coaching staff, which is usually a mom or dad in their after-school program.

Another thing that bothers Dr. James Andrews is the scary misconception among youth players that "pitchers should get Tommy John surgery as soon as possible so they will be better for college and they will be able to throw harder after surgery." The ASMI found a surprising 25 percent to 50 percent of amateur players, parents, and coaches believe this to be true Dr. James Andrews says it is not true. Indeed, MLB pitchers often show some improvement in performance upon return from Tommy John surgery. However, such improvements for a professional or amateur pitcher are due to the surgeon fixing the problem; followed by the pitcher working intensely with the physical therapist, athletic trainer, strength coach, and pitching coach. The time without pitching after surgery also helps the athlete's body. Performance eventually decreases over time for MLB pitchers after Tommy John surgery (similar to the typical decrease over time for healthy MLB pitchers).

It is also important to realize that 10 percent to 20 percent of pitchers never make it back to their previous level after Tommy John surgery. My client / pitcher did make it back and was able to perform two more years, and left the game as the top closer for an overseas team.

What Should Treatment Look Like After Surgery?

#1: Remember the length of time it takes for this tendon to act as a ligament. You need to have the thought process that you are a part of a team effort to get this athlete back in the game. My client / baseball player had to take my CV to the team physical therapist, and then we had to have a meeting before I was allowed to treat him. The physical therapist clearly stated that a massage therapist he had trusted before had ruined a player's arm that he had been treating, so he would never consider referring out again. My client / ballplayer assured the physical therapist that I would listen and follow whatever he wanted me to do and not do.

#2: I never started stretching or isometrics before the physical therapist had indicated it was OK to do so. Timing is everything after any surgery and rehabilitation is performed in stages for a reason, just like following a recipe. One misstep and you have a failure on your hands.

#3: After he finally came out of the brace and they allowed me to do treatment, my client / pitcher's elbow was left with a problem of a biceps contraction, leaving him at a 30 degree flexion angle. The therapy goal is to achieve zero degrees of elbow extension. My treatment started very gently, utilizing a major amount of contrast therapy and very light cupping. The next visit he had showed improvement of about 10 degrees. This time, I spent up to two hours of hot packs, massage cupping, and PNF stretching with no passive movement on my part; all active movement on his part. I keep alternating the treatment on his arm by addressing all of the other muscles that had gotten tight over time, such as his pectoralis, subscapularis, trapezius, levator, SCM, etc., while the heat was on his arm.

Keep in mind he was still going to physical therapy and to achieve full recovery and zero elbow extension, his therapy was daily. The good news is within two weeks he had full extension. Each visit was approximately 1 ½ hours of using several modalities to override that biceps contraction, which is very common after a Tommy John surgery.

The takeaway from this story is recognizing the length of recovery that is necessary for an UCL to heal and educating your community on the prevention of UCL surgery. Encourage moms and dads to understand the need for time off, playing multiple sports, and the fact that and nothing good comes from playing through pain. A longer playing career and less possibility of burnout are other benefits. My client / pitcher made it to the majors by playing three sports in high school, taking the last year of high school off from baseball. He always took 4-6 weeks off after the season before training and throwing again to get ready for spring training.

He had great kinematic sequencing in his pitches, which was created by his dedication to functional training, chiropractic, acupuncture and massage therapy. I would like to invite you to read my July 2011 article ["Team With Pro Athletes: A Win for Everyone"], to read more on how he felt massage therapy had helped his recovery.

"The most certain way to realize our own dreams is to help others realize theirs." — Mary Anne Radmacher

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