October professional playoff baseball is the greatest time of the year for baseball fans, but it is also the hardest time for amateur players to get injured..
“Dress warm, it’s cold here in Boston.” That’s what the Yankees athletic trainers told me last night just before getting off the phone with them. I stayed back in New York to see patients rather than travel with the team after Sunday evenings victory. As I now head to LaGuardia for a shuttle to Boston, it indeed feels like October fall baseball weather. I said goodnight goodbye to my kids last night before bed and they were both anxious and excited for the Yankees vs. Boston wild card game. And they very much enjoy fall playoff baseball because my wife and I allow them to stay up late until the games are over.
I myself am excited for Yankee playoff baseball, however, I am also thinking about a patient I saw earlier this week. A young dedicated and talented baseball pitcher who travelled a few hours for his office visit. He had the same twinkle in his eye as all young baseball players. A hopeful aspiration to play at the highest levels. He too is a Yankee fan and is feeling the highest level of Yankee excitement. (FYI not all my patients are Yankee fans, many are Mets or Boston fans!).
Unfortunately, I have to deliver his elbow MRI findings that demonstrate a significant UCL tear. He has been resting for the last two weeks and says he feels normal with routine activities and even strength training. I can tell by the way he is explaining how good he feels that he believes he will be better soon and back to pitching. When I palpate his UCL and when I manually apply stress to his UCL, he does admit to having some discomfort.
After pointing out the MRI images on the computer screen, I pause so that he and his dad can process the injury news. The twinkle in his eye is lost and his eye contact is intermittent. His diagnosis of a partial UCL tear is clear and without controversy. His treatment is much more tricky.
I then begin explaining the options. “There are two options, surgery or no surgery. Let me walk through each option with you which will be helpful for your decision.” I go on to outline that non-operative treatment requires a six week period of rest from throwing, therapy to build up strength and flexibility, and then a process of progressive throwing. I also discuss PRP injections to enhance healing potential of the damaged UCL.
Non-operative treatment maintains the opportunity for him to pitch this spring of 2022. He is particularly interested in pitching this spring because he anticipates getting scouted and even drafted. However, there are significant downsides with non-operative treatment. If his UCL does not heal well enough, he may very well develop symptoms in the upcoming spring season. This will require him to shut down and potentially even have Tommy John Surgery. This means his 2022 season and also his 2023 season will be compromised. He did not pitch last year in 2020 because of the covid pandemic. The net result would be three consecutive years of compromised baseball. In addition, some pitchers with a compromised UCL have a challenging time performing well with the status of their UCL ever present in the back of their mind. They feel like they’re walking on eggshells and ready to pop their UCL anytime. Lastly, and perhaps an unattractive part of an amateur player’s future is that professional teams interested in him will in all likelihood get access to his MRI scan and discovered that he has a compromised UCL. This will change how they value him compared to other pitchers on their draft board.
Option B is to have immediate Tommy John Surgery or UCL repair with internal brace. The benefits of surgery are several. The 2023 season will be more predictable, he would not have to walk on egg shells wondering if his UCL was going to tear at any time. This can eliminate a very powerful negative psyche. It would allow him to continue in his development as a pitcher and would overall enhance his draft potential. He would be in position to increase his intensity of pitching with a healthy UCL. The disadvantage of immediate Tommy John Surgery is sacrificing the 2022 season altogether, going through the procedure itself, and the grueling rehab.
The purest indication for Tommy John surgery is a history of pain interfering with throwing, a positive physical exam, a positive MRI scan, a desire to continue playing, and also failure of non-operative treatment. However, the complexity of seasonal timing and career aspirations greatly impacts the decision in addition to the degree of injury and failure of non-operative treatment.
October professional baseball is the greatest time of the year for baseball fans, it is also the hardest time for amateur players to get injured.