The Challenge of Tommy John Rehab During the Coronavirus Pandemic

My last day of surgery prior to shutting down our operating rooms to care for coronavirus patients was March 6. Out of 14 operations that day, the majority were elbow surgeries on baseball players. A Tommy John surgery followed by another Tommy John surgery is the norm on both my Wednesday and Friday operating days in February and March each year.

Tommy John surgery typically takes 45 to 60 minutes to complete. It is amazing that the procedure that takes the same amount of time as 3 innings of baseball demands an overall rehabilitation time of 12 to 16 months. The lengthy rehabilitation is physically and mentally demanding and essential for success. For many young athletes, the rehab process improves their overall mechanics, strength, and overall training discipline. This often translates to increased velocity and performance following surgery. TJ rehabilitation is so critical that I spend time working side by side with physical therapy baseball specialists, strength and conditioning coaches, and baseball sports scientists to continuously refine and optimize general protocols and to meet individual player needs.

On Mondays, I spend my day at the performance center where I make rounds in the physical therapy and strength and conditioning areas to check on recovering athletes.

An Unforeseen Challenge

An enormous number of my patients who had Tommy John surgery in the days, months, and season prior to the coronavirus pandemic suddenly faced an unforeseen challenge. Social distancing required patients to avoid congregating, and many rehabilitation facilities needed to shut down or significantly decrease the amount of rehabbing patients they could treat. The performance center that I work at completely shut down. Players could not access me, their TJ physical therapy experts, or their strength and conditioning coach when they were most vulnerable. In addition, those athletes that were later in their rehab who needed to start or continue their interval throwing program, now had limited access to baseball training environments, pitching coaches, and more simply… people to throw with.

Coronavirus has presented players with unforeseen challenges

After their Tommy John surgery, patients have scheduled follow-up evaluations with me at time intervals from the surgery at 2 weeks, 6 weeks, 3 months, 4.5 months, and so on. Each time point has a specific action step to the rehab process. If elbow motion at 6 weeks is inadequate, therapy is modified and perhaps an anti-inflammatory medication is started as an example. At 6 weeks we discontinue the brace if strength is adequate. At 4.5 months, we start a throwing program if the evaluation reveals the patient is ready. Essentially you walk before you run, and our experts check to make sure you can walk perfectly.

So how did we and our patients respond to the abrupt COVID rehab obstacle? We got creative and expanded our tools. We initiated and went full force with virtual sports medicine…

What is virtual sports medicine?

I have been doing virtual medicine for many years to make sure baseball players who travel from all over the country to have Tommy John surgery with me receive great follow-up care and optimized rehab. A virtual visit is just like an in-person office visit. We connect using a specific platform that is similar to Facetime and use either a smartphone, tablet, or computer screen. I discuss details of their rehab exercises, throwing, and how their body and elbow are feeling exactly as would take place during a traditional office visit. Then I do various virtual physical examination maneuvers where patients mirror an exam that I am doing on my own elbow. Patients show me their incision, activate specific muscles to look for any atrophy, and they flex and extend their elbow to demonstrate motion. Patients can easily show me their ulnar nerve function.

Finally, I have developed a method to virtual test the Tommy John reconstruction to make sure it is healing properly.

Virtual sports medicine is a tremendous tool that allows me to keep the TJ rehab going regardless of distance. Patients can discontinue their brace or can be deemed ready to start their throwing program when safe and appropriate.

Virtual Physical Therapy

We also created a platform for our Tommy John physical therapists. A huge benefit of virtual physical therapy is that it eliminates travel issues for patients that live at a distance from our rehab facilities. This has been especially helpful to those talented pitchers who do not have regular access to baseball physical therapists whether currently, or during the non-COVID world. Now, these patients can get on the platform and work with our therapists from their homes.

Safe progression in rehab requires completing and achieving exercise goals before progressing. If a patient’s form is poor, or if endurance is not quite there, progression is slowed down. Strength and integrative movements are the foundation for a successful return. Like a house with a strong foundation that can withstand earthquakes and hurricanes. Virtual physical therapy makes sure the progress keeps going.

Many players have been rehabbing with the assistance of family members and many are extremely creative and motivated. Our players during their rehab process have been throwing in their backyards, against their garage doors, and have made make-shift backstops with a custom mound. Our physical therapists and my team of athletic trainers have worked with players to transform home environments into well functioning rehab environments. While the situation is not ideal, patients are continuing to recover well. Some mom and dads have actually developed shoulder pain from throwing with their kids at home. (We are able to help them with virtual sports medicine as well!)

Yesterday I was on virtual appointments with 6 players rehabbing from Tommy John surgery. They were all excited for the warm weather as they continued with their creative throwing. One college player, Trevor B, explained “I have been throwing against a wall and sometimes against a backstop by myself. My arm feels great!”

Thankfully, virtual sports medicine along with new creative examination methods and supervised rehab has helped solve the coronavirus social distancing challenge to Tommy John rehab. Likely, virtual medicine will continue in one form or another long after the coronavirus epidemic is over.


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