Ligaments, Tendons, Tommy John Surgery and Office Ergonomics!

6/13/2011

Last week the sports world announced that another baseball pitcher, reliever Joba Chamberlain of the New York Yankees has sustained a torn ligament in his elbow and will need Tommy John Surgery.  “Tommy John Surgery?” I asked myself.  “What is that?”   

Tommy John Surgery is a medical procedure in which a ligament in the medial (or middle) elbow is replaced with a tendon from elsewhere in the body.  Often the tendon is taken from the forearm, hamstring, knee, or foot of the patient.  The medical terminology is better known as ulnar collateral ligament (or UCL) reconstruction (meaning a ligament associated with the ulnar – the larger of the two forearm bones). The procedure is common among collegiate and professional athletes in several sports and, as we already know, most notably baseball.

The surgery is named after Tommy John, a pitcher who was the first professional athlete to successfully undergo the operation. The procedure was performed by Dr. Frank Jobe in 1974, who today serves as a Special Advisor to the Los Angeles Dodgers.

The ulnar collateral ligament (internal lateral ligament) is a thick triangular band consisting of two portions, an anterior (from the front) and posterior (situated in the rear) section united by a thinner intermediate portion. The term ligament is most commonly used to denote fibrous tissue that connects bones to other bones. A tendon (or sinew) is a tough band of fibrous connective tissue that usually connects muscle to bone and is capable of withstanding tension. Tendons are similar to ligaments as they are both made of collagen.  Tendons and muscles work together.

After the tendon from the forearm of the same or opposite elbow or below the knee (or from a cadaver) is harvested it is then woven in a figure-eight pattern through tunnels that have been drilled in the ulna and humorous bone that are part of the elbow joint.

Aside from baseball pitchers getting their ligaments and tendons hurt, in the real world ligament tears and tendon inflammations occur with an unfortunate frequency.  Slips, trips and falls and awkward positioning (including improper lifting techniques) are, of course, significant contributors to ligament tears and damaged tendons.

Tendon disorders are medical conditions involving one of two types of tendons: tendons without sheaths (tendon coverings) and tendons with sheaths and are referred to as either tendinitis or tenosynovitis. Tendinitis is a disorder of tendons without sheaths and tenosynovitis is a disorder of tendons with sheaths. Tendinitis (also called tendonitis) is the term used to describe an inflammation of tendons. Tendons are rope-like structures made of strong, smooth, shiny fibers. With repetitive or prolonged activities, forceful exertion, awkward and static postures, excessive vibrations, and localized mechanical stress, the tendons fibers can tear apart in much the same way a rope becomes frayed. These tendon changes trigger an inflammatory response. Thus, inflammation is a localized response of tissue to injury. Over time, inflamed tendons become thickened, bumpy, and irregular. Without rest and time for the tissue to heal, tendons can become permanently weakened. Tenosynovitis (inflammation of tendons with sheaths) is an inflammation of the actual tendon sheath, which is a layer of membrane around a tendon. The inner walls of the sheath produce a slippery fluid, called synovial fluid, which lubricates the tendon. With repetitive or prolonged activities, forceful exertion, awkward and static posture, vibration, and localized mechanical stress, the lubrication system may malfunction. Due to excessive abrasions, this condition can lead to inflammation and swelling of the tendon sheath. Repeated episodes of this condition will cause the fibrous tissue to form a thickening of the tendon sheath and therefore, hamper tendon movement.

In the office environment, computer injuries often are caused by damage to a ligament or tendon, resulting in a sprain or tendonitis.  These conditions are often referred to as repetitive strain computer injuries. Tendons of the wrist flexor and extensor muscles and the intrinsic muscles of the hand are subject to overuse-induced computer injuries, including the very common tennis elbow.  Injuries involving the flexor retinaculum (wrist ligament) are a primary element of the most frequent computer injury, carpal tunnel syndrome, where this ligament becomes restricted, followed by inflammation and swelling, thereby narrowing  the space in the carpel tunnel (pathway for nerves and blood vessels in the wrist), and often compressing the nerves and blood vessels.

How can we prevent tendon disorders? The prevention of tendon disorders should include identifying and remedying these risk factors. A properly designed work station as well as good work practices – such as taking frequent short breaks away from your work station (typically five minute breaks every hour) as well as using well-designed equipment should aim at reducing repetitive movements. Such equipment may include an ergonomically-designed keyboard or mechanically articulating components. Awkward postures and static posture (periods spent in one position) also need to be discouraged. This will require persons to be cognizant of his/her work habits so that they may identify the potential strains they are placing on themselves. Job design should also aim at minimizing the need to use forceful exertion and making sure that rest and work breaks are properly used. This may require a little assistance from your Safety and Health professional or computer/IT specialist so that your work station can be properly evaluated.  Keyboard height and angle, proper screen height, and a well-designed chair are all essential. A basic factor for avoiding computer injury is keeping the wrist in a neutral position during usage. With long hours of computer usage – common in occupational situations and other activities – avoidance and treatment of computer injury is a primary element of health…and of course, be careful when throwing a baseball!

Look at a stone cutter hammering away at his rock, perhaps a hundred times without as much as a crack showing in it.  Yet at the hundred-and-first blow it will split in two, and I know it was not the last blow that did it, but all that had gone before. 

Jacob A. Riis (American Journalist: 1849 -1914)