Joe Nathan – Elbow Surgery on his Ulnar Collateral Ligament

By Asheesh Bedi, MD

With the Major League Baseball season set to open this weekend, surgery on Twins’ All-Star Joe Nathan’s elbow this past week reminds us of the unique injuries that can affect throwing athletes. Overhead athletes place unique and unusually large stresses on their shoulders and elbow, and the repetitive activities of their sport can result in chronic injury to the stabilizing tissues of their joint. Nathan suffered a rupture of his ulnar collateral ligament of the elbow and underwent reconstructive surgery with renowned surgeon, Dr. David Altchek, this past week in New York. 

The ulnar collateral ligament (UCL) is a tight band of tissue that connects the distal part of the inner arm bone (“humerus”) to the inner bone of the forearm (“ulna”). In this location, it resists the deforming forces that are placed on the elbow with forceful, overhead throwing. While it is believed that the athlete’s pitching mechanics and types of pitches may affect the risk of injury, the greatest determinant appears to be the number of pitches thrown. Chronic, repetitive “microtrauma” to the ligament results in stretch followed by traumatic rupture. The athlete may complete of a single “popping” event accompanied by medial elbow pain and a loss of velocity on their pitches. Physical examination will reveal increasing opening and/or pain along the inner aspect of the elbow joint with provocative stress, and an MRI will often confirm the diagnosis. While many recreational athletes may be able to rehabilitate and subsequently function at a reasonable level without surgery, most competitive athletes require reconstructive surgery to return to their previous level of competition and regain the velocity on their pitches. With the increasing participation of kids in throwing sports at a younger age, the injury is being seen with greater prevalence over the past few years. In kids, the injury is often seen as an avulsion from bone (“medial epicondyle fracture”) rather than rupture of the ligament.

Reconstructive surgery for the UCL consists of recreating the anatomy of the medial elbow using a tendon graft that is harvested from elsewhere in the body, usually from around the wrist or knee. The recovery typically requires a minimum of a year, however, as the tendon must heal to bone before it can safely withstand the significant stresses of the throwing motion. The athlete must also complete a carefully designed and customized throwing program to gradually transition from short and long tosses to high velocity pitches. The decisions on goals, expectations, and progress are individualized and dependent upon input from the patient, treating surgeon, athletic trainers, and throwing coaches.

We look forward to seeing Joe Nathan throwing K’s on the mound in Minneapolis and wish him a uneventful and speedy recovery. With the season openers just around the corner, however, it is important to consider the unique physical demands of baseball.

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