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UCL Injuries in Baseball & Tommy John Surgery Podcast Transcript
Host: [00:00:10] Welcome to the Mayo Clinic Orthopedic Surgery Podcast, a curated series of interviews and discussions highlighting the three shields of orthopedic surgery at Mayo Clinic, clinical practice, research and education.
Dr. Okoroha: [00:00:32] Welcome back to the Mayo Clinic Orthopedic Surgery podcast. I'm your host Doctor Okoroha, and I'm really excited today to welcome Dr. Christopher Camp. Now, Dr. Camp was a previous collegiate baseball player who probably would have put my college career to shame Dr. Camp is, an associate professor of orthopedic surgery at the Mayo Clinic. He completed his residency at the Mayo Clinic before doing his sports medicine fellowship at the renowned Hospital of special surgery. Now, Chris has had a remarkable research career that includes many awards and research in the areas of baseball injuries and prevention, patient outcomes and surgical optimization.In addition to his busy clinical practice and academic efforts, Chris also serves as associate program director for both the residency and the sports scholarship. If that is not enough,he also serves as a team physician, medical director and director of high performance for the Minnesota Twins. So, as you can see, Chris is a very busy man, so it's a pleasure to steal him away for a podcast. Welcome, Chris.
Dr. Camp: [00:01:31] Thanks, Kelechi, I really appreciate you having me join you. And I'll tell you, I think that my college baseball career, I spent more time on the injured list than on the playing field. So,that probably makes me a better orthopedic surgeon than an actual baseball player. So, I don't think any of that counts at all. And I think I know you spent a lot of time out on the court.
Dr. Okoroha: [00:01:50] Yeah, I think we both made the right decision in the end. Right. All right. So today we're going to be talking about Tommy John surgery. And so I know a lot of people have heard about Tommy John surgery, but what is the current thinking about Tommy John surgery? And is it still thought to be caused by overuse? And then why are we seeing increasing rate of injuries in our younger players recently?
Dr. Camp: [00:02:12] Great thoughts. Great questions. As you know, it is something that is a very hot topic right now. It's one of the most common injuries in baseball players. And the part of the problem is not only is it a common injury, but itcan also be a relatively severe injury. And so, when somebody has an injury, they often have to have surgery. And if they have surgery, they may be out for six months, 12 months or maybe even longer. So, it is very important, very critical. The other concerning factor that you mentioned is that injury rates are really on the rise. And we've known that for a while in professional baseball players, in Major League Baseball players. But more recently, we're starting to see an even faster growth in younger players. And that's minor league, college, high school and even some youth players, too. So, it is extremely concerning. The younger players are actually experiencing the greatest growth in injuriesin a couple of studies. A study we did recently showed that fortunately it's actually trending downward in Major League Baseball, which is good. But the problem is that's being met with a reciprocal and dramatic increase in the minor leagues.
Dr. Camp: [00:03:21] So what we initially thought was good news that injury rates were going down in the major leagues, turns out they're not (going down for everyone). The issue is that these injuries are shifting to younger and younger players. So, the fact that it's such a severe injury and it's on the rise are really the things that that have us concerned and paying a lot of attention to it. And you mentioned what are the causes of it? This has been studied extensively, and you and I have both been passionate about this and tried to investigate and do some research on it. And I think if you if you sum up all the research that's been done, there's really three things that that consistently seem to increase the risk for Tommy John injuries. And they're either 1. throwing too hard with high velocity, 2. throwing too much or 3. throwing with poor mechanics. Those three factors, I think really, if you try to sum up the world's literature and the world's research on it, that's what we would find. Those three things are really the main culprits.
Dr. Okoroha: [00:04:22] What about strength and conditioning? And is there anything we can do to decrease the incidence in younger players?
Dr. Camp: [00:04:31] Yeah, absolutely. I think one of the things we're starting to learn, too, is the line is getting blurred a little bit between the weight room versus the training room versus the doctor's office versus on the field and on the mound. And really all of those areas, all of those domains really kind of need to understand one another so that the player and the pitcher has sort of a holistic approach to their care. You know, you don't want them in a situation where you have the doctor who's just looking out for their health or the coach who's just looking out for their performance or the strength conditioning, who's just trying to make them stronger. I think really what has to happen is that all of those groups really need to be on the same page. And I think that there is a way that we can help these athletes get better, get stronger, get faster, throw harder, in a safe way where they don't get hurt. And I think that a lot of that charge and responsibility is on us as the orthopedic provider to help sort of bridge that gap and understand what their programming is, understand what they're doing in the weight room, understand what their offseason throwing is, what they're doing to try to increase their throwing velocity if they're doing that. So, I think it's critical for us to try to understand that and not necessarily tell them they can't, but to talk to them and educate them and show how they can do it in a way that's safe and will help prevent future injury.
Dr. Okoroha: [00:05:54] All right, great. That's very important. And so, let's say we have this young pitcher who sustains a UCL injury. We know that there's different severities of injury. So how do you go about evaluating, let's say, a sprain versus a complete rupture? And I know you just performed actually a couple of these surgeries today. What are your indications for surgery versus conservative management?
Dr. Camp: [00:06:13] Yeah, so I think first, you know, making the diagnosis can be tough. A lot of pitchers have pain on the medial aspect of their elbow, the inside aspect of their elbow. And there's really three main reasons for pain on the inside of the elbow in the throwing athlete. And that's either a 1. Tommy John injury, which we're talking about today. 2. A strain of the flexor/pronator muscle tendon group or 3. an ulnar nerve problem. So that's the first thing, is trying to sort those out. There's different things we can ask them, the history and do anexam to help distinguish those. For most elbow pain, if you catch it early, tends to be mild sprains, very calm, a little flexor tendinopathy and will improve with some rest. But the physical exam really helps bring that out. And then also, in addition to the physical exam, obviously advanced imaging can be really helpful. So, looking at the ligament with an MRI or performing a stress ultrasound of the elbow to see if there's any instability can also help. So, we've got a lot of tools in our toolbox that we use to help distinguish between those three things and not only help make the diagnosis, but also try to determine how bad the severity is. So. You know, you mentioned how do you make the decision of surgery versus no surgery? There's a lot of ways we talk about severity of ulnar collateral ligament injuries. There's a few different ways that we look at it. We like to know the location of the injury. Is it proximal in the middle or distal? And we also like to know the severity. Is it a low grade, partial tear, high-grade partial tear or a complete tear? And sort of putting together some of those factors and characteristics can tell us if there's a chance that this would heal with just rest and non-operative treatment or if this is one that has a very low rate of success with non-operative treatment. Maybe they need surgery sooner rather than later.
Dr. Okoroha: [00:08:00] Great, really great information. And sorry, I've heard you've been developing this new surgical technique called the anatomic UCL reconstruction. Can you tell us a little bit about that?
Dr. Camp: [00:08:10] Yeah, so we've been working on developing a technique that's more biologically friendly and biomechanically stronger than traditional UCL reconstruction techniques. And really, they haven't changed much since the early 2000s. The docking technique and the modified Jobe technique were described in 2000, 2001, 2002, right around that time. And they haven't changed a whole lot since then. And they're great techniques. They work very well. High rate of success, you know. Eighty five to ninety five percent of pitchers get back with that, which is which is great. The problem is it takes a really long time. On average, it's somewhere between 12 to 16 months for professional pitchers to get back after the surgery. On the flip side, we know that NFL players can get back after multiple leg, multi ligament knee injuries and in sometimes 12 to 13 months. So why is it that somebody can tear every ligament in their knee and get back sooner than just one tiny little ligament on the inside of the elbow? So even though the return to play rate is good, I think there are some things we can do to improve the return to play time. So, we’ve sort of redesigned the technique. We flip the graft. Now it goes in the opposite direction. There's less suture inside the tunnel, and the sockets. And so we have more tendon to bone contact, which makes it more biologically friendly. And then we use a few more points of fixation, which makes it biomechanically stronger. So, the hope is that with the increased biomechanical strength, it may be safer to start throwing a little bit earlier because it's a stronger construct. And with it being more biologically friendly, it may heal faster as well, which may let them return to play a little bit sooner. So far, we're seeing some encouraging results and we're going to continue to study it.
Dr. Okoroha: [00:09:59] Nice. Is there any early research out about it now.
Dr. Camp: [00:10:03] So far we've published a cadaveric study looking at overall biomechanical strength, and it showed that it was stronger than the docking technique, which is the sort of historic gold standard. And it actually had a similar load to failure as the native older collateral ligament. So, it seemed to mimic normal anatomy, which is usually a good thing. And then we're following our patients clinically. And so far after reconstruction, we've had pitchers getting back as soon as six months, playing in games afterwards and doing well. So, typically what I do now is I offer patients thathave had an anatomic reconstructionthe opportunity for an accelerated rehab, and we map that out for them. And then if they have any troubles, issues, setbacks or problems with them, we're very quickly will pull them back and slow down and maybe convert to a more traditional pathway that might be more like 12 months.
Dr. Okoroha: [00:10:52] That's awesome. So normally it's about nine – 12 moths, but you see them return as early as six months with this new technique?
Dr. Camp: [00:10:57] Yes. Which is also really encouraging. Encouraging that can be helpful to some that can save a season for a college senior or high school senior who may not get to play otherwise. So, it can be helpful.
Dr. Okoroha: [00:11:08] That's awesome. So, we know in the knee, we use many different graphs. Basically, it's a patient specific based on the injury and then thepatient profile. What is your graph choice for UCL reconstruction?
Dr. Camp: [00:11:21] So for the UCL, particularly in high level competitive athletes, I prefer autograft as opposed to allograft. So autograf, Meaning that it comes from the patient's own body, not from a donor or a cadaver. And my go to graft is the Palmaris Longus, which is in the wrist. And so you can see right here, this little strand of tissue in my wrist. That's the go to if they have it. But not all patients have that. About 10 to 15 percent of the population don't have a palmaris longus tendon in their wrist. So, if that's the case, then we actually take a small strip of the hamstring tendons out of their knee, and we usually do it from their opposite knee. We do it on the side that they would be landing on when pitching, not the side that they push off from, because they probably need that extra strength for the push off leg, but it's less critical in their landing leg.
Dr. Okoroha: [00:12:14] Okay. And so what do you tell players who asked about getting Tommy John surgery so they can pitch faster? I know we all have those patients that come in like, hey, I heard about this Tommy John surgery. I want to get it so I can throw faster. What do you tell those patients and how do you manage expectations following surgery with players who think their performance is actually going to increase after the surgery?
Dr. Camp: [00:12:33] Yeah, that's a fantastic question. And I think that a lot of players know people who ended up coming back and throwing harder than they did previously. But on average, when this has been studied, that is not the case. If anything, they lose a little bit of velocity or lose a little bit of performance. So, I try to coach them on that just to make them aware. But I think for those few players that do see a boost or an increase in their performance. Probably has nothing to do with the surgery itself, but my thing is that probably has to do with the arm care and the strengthening in the rehab and the throwing program that they do afterwards. So, I use that as motivation for the patients. And I say, you know, there's no guarantee. However, your best chance is if you really stick to the program, you do the therapy, you do the throwing program as we have it lined out for you, that gives you your best chance of being one of those players that reaches the same or maybe even better level. But that should not be the expectation.
Dr. Okoroha: [00:13:32] I think you put that well. Is there anything that we should be using to monitor these players to potentially avoid injury or any new technologies?
Dr. Camp: [00:13:42] Yeah, there's a lot and this is a big area of interest for me, and this is a quickly developing area. You know, I mentioned earlier that the three things that cause Tommy John injuries, throwing too hard, throwing too much or poor mechanics. Well, we're never going to get pitchers to stop throwing hard. So, if you if you tell a player, stop throwing hard, you've lost and they're not going to listen to you. So, you might as well not even bring that one up. We have to work on the other two, either throwing too much or throwing with poor mechanics. Historically, it's been difficult to evaluate a player's mechanics unless you have them in a lab with a bunch of cameras around and doing motion capture. Now there's newer technology that's coming out where there's different wearable devices, or you can record yourself throwing on a video and get some sort of analytics on your pitching performance just based on that. I think as we see that technology get easier and cheaper and more portable, we're going to have the ability to help more pitchers work on their mechanics. That'll be younger pitchers, maybe high school kids or even younger will now have the ability to do some of the things that all the big league guys are doing as well. I think that technology has really taken off in the last five years or so. There's a lot of work that needs to be done on validation, and we've been involved in a lot of that research here at Mayo. And I think we found some of the technology is not very good. Some of it is pretty good. So, we're going to have to sort through that in the next couple of years. But hopefully pretty soon we'll get to a spot where we have something that's cheap, easy and accessible and understandable, very simple for the masses, not just for Major League Baseball players.
Dr. Okoroha: [00:15:21] Do you have any tips for young surgeons who are trying to perform UCL reconstruction?
Dr. Camp: [00:15:26] Yeah, absolutely. I think just like with any technique you really need to hone your clinical skills.Make sure you see a lot of patients that have had the injuries and hone your exam skills, your ability to interpret images, and then also surgical skills as well. Now, it is a great surgeon who has a higher rate of success, but there are some risks involved. Certainly, different things have been reported, ulnar nerve injuries, medial epicondyle fractures and problems like that. So, you really want to make sure that you have a good handle on the surgical technique as well.I think it's something that takes a lot of practice. Get into the lab, go spend some time with somebody who does a lot of them. Shadow, do whatever you have to do to see a high volume and a lot of reps before you decide to take it on. And the other thing I would say, too, is if you're going to do that, you really need to partner with the good physical therapist who understands the throwing motion, throwing mechanics as well, and can help you develop throwing programs and rehab programs after surgery or for the patients you're treating on operatively. It's something that you really can't do on your own. And we're very blessed here at Mayo that we really have a team everybody from athletic trainers to physical therapists to non-operative sports medicine and PM&Rphysicians to orthopedic surgeons who all have a special interest in the overhead throwing athlete and baseball players. That's been extremely helpful for us to take that team approach.
Dr. Okoroha: [00:16:46] That's really great advice, Chris. So, I'm going to summarize the key points that I took notes on from you here. You said the UCLA injury is common, but it's severe. Traditionally, it's been on the rise in professionals, but now it's shifting to those younger players. Three things you really kind of hone in on (for causes of injury)is throwing hard, throwing too much and poor mechanics. There are three things you have to evaluate on the medial side of the elbow and that the UCL, a flexor strain or ulnar nerve injury. And the key to doing that is doing a good physical exam and getting advanced imaging when you can.Deciding between surgery and nonsurgical, you're looking at location, so that is it the proximal aspect, the middle aspect or the distal aspect. And is it a partial or complete tear? You told us about your new anatomic UCL reconstruction, which combines improved biology and structure to try to get those players back at a faster time point. And you also want to manage expectations after surgery. And finally, you talked about some technology that's going to help us monitor the mechanics and teach players with more wearable devices.
Dr. Camp: [00:17:51] You got it, I think that's an excellent summary.
Dr. Okoroha: [00:17:54] Any other thoughts about people who are interested in a surgery or research that's coming out in the near future?
Dr. Camp: [00:18:00] Yeah, I think this is a very exciting field. We have a lot to learn. It's not something that we're going to have a quick answer to. So, you know, if you look at the ACL, we've been looking into that and investigating and studying it for, you know, 30, 40 years now. And we still argue about the best way to do things, and we're still learning new things. And I think to use this is going to be no different. There's a lot of interest in it now. We're not going to have all the answers any time soon, but we're going to keep asking the questions and try to figure out as much as we can. So, I think it's really exciting times.
Dr. Okoroha: [00:18:30] All right. Thanks for your time today, Chris.
Dr. Camp: [00:18:32] You got it. Thank you.
