Interview with Dr. Nate Marshall
Interview with Dr. Nate Marshall
By Scott Bolohan
When I got the MRI results that my UCL was torn, I went to see Dr. Nate Marshall in Rochester, MI. He was happy to talk my decision over with me, especially as a more untraditional candidate for Tommy John. He came highly recommended, for good reason.
After graduating from Wayne State University Medical School, Dr. Nate Marshall had a fellowship with the inventors of Tommy John surgery at Kerlan-Jobe Orthopedic Clinic and worked for numerous professional and college teams. He’s also the author of over 25 peer-reviewed studies. We asked him about his experiences performing Tommy John surgery, what it’s changed over the years, and what its future holds.
I think a lot of people don’t actually know what the surgery is, can you walk us through what happens?
That all starts with what is wrong in the first place. The ligament of concern is the ulnar collateral ligament (UCL) of the elbow, which is the ligament that goes from the end of the arm bone (humerus) to the top of the forearm bone (ulna) on the inside part of the elbow. This ligament is what resists stress at the elbow as your arm goes out, most significantly, as we pull our arm back and pull through during a pitch to create that stress at our elbow and at the ligament. That is the ligament that tears, and to treat that tear, we are actually replacing that ligament with a new one.
To replace that ligament, or what we refer to as a reconstruction, we use a tendon from somewhere else in the body that is not needed for full function. The most common tendon used is the palmaris, which is absent in some patients (again, lending evidence that it isn’t necessary for full function), and this is found in the wrist and forearm. The second most commonly used is one of the hamstring tendons, which are commonly used in ACL reconstructions.
This tendon is harvested at the time of surgery. There are then small bone tunnels drilled into the ulna bone and into the humerus bone (where the ligament attaches to) and the tendon that is harvested is then passed through these tunnels and secured in place to create a nice tight tendon to take the place of the previously damaged ligament.
The reason recovery after this reconstruction is so long, is that your body, as it heals, will then change this tendon into a ligament (ligamentization), and that can take a year to do so.
What’s your background with Tommy John surgeries? How many have you performed? How many do you think you do in a year?
Tommy John surgery was invented by Dr. Frank Jobe back in the 1970s. At the time, he was the team physician for the LA Dodgers and continued to have pitchers that sustained this injury, and at the time, it was then a career-ending injury. Because of this, he developed the “Tommy John” surgery to “transfer” a tendon to take the place of the ligament. It is called Tommy John surgery, because the pitcher Tommy John was the first to undergo the procedure. Tommy John, then went on to play an extended career at the major league level and continued to give evidence to the procedure. Dr. Jobe is also one of the founders of the Kerlan Jobe Orthopedic Clinic in Los Angeles. As part of my orthopedic training, I did my sports medicine fellowship at Kerlan Jobe, which still serves at the epicenter for Tommy John surgery and treats many of the MLB pitchers we hear about in the news for this injury. During my training, I therefore had a vast amount of experience with this surgery. At the time, I worked closely with Dr. ElAttrache, who originally began working at Kerlan Jobe when Dr. Jobe was first beginning this surgery, now continues to treat most of these athletes today. Luckily, it’s not a very common injury, compared to ACL tears or rotator cuff tears, so, depending on location, even doing one Tommy John surgery a month is quite a bit.
What should someone thinking about having the surgery consider? What’s the biggest misconception about the surgery? What are the biggest concerns or complications with the surgery?
The biggest thing to consider with surgery is always your function. With regards to the UCL, for most activities, we don’t need the ligament to function, but for pitching, specifically, we do. We hear about the ligament and surgery mostly in the MLB pitchers, because this is where we need the ligament to function the most at the highest level. For example, if you are in your senior year of high school and never plan to play again at a higher level, the surgery may not be of benefit to you. Versus, if you are planning to play in college or at a high level, you demand more function out of your elbow.
Recovery typically takes anywhere from nine months to a year after surgery, so that is the next consideration. Looking at time frame for recovery, where you are at in your career, etc. The final consideration is then what am I not able to do because of my elbow. If you need to pitch or throw and you are unable to do at the level you need to, then a reconstruction would be beneficial.
The biggest concern for surgery is not getting back to the previous level of play. We have shown in previous studies that the surgery is good for returning to previous level of play, but at the MLB level this can sometimes be as low as 80%. However, this can be as high as 95% for return to all levels. The biggest surgical concern is usually complications with the ulnar nerve (“funny bone”), which is protected at the time of surgery, but can have complications post-operatively with inflammation of the nerve or irritation, which is the most common reason for reoperation.
Have you noticed any trends in who is getting the surgery? Is there a typical patient you see and has there been any changes in that over your career? Are there concerns for people of different ages? Is there a minimum or maximum age you would do the surgery on?
The injury and surgery are much more known nowadays and there are a lot of misconceptions in the public about this. Because of this, more high school-aged pitchers are sustaining and treating these injuries and even younger players at times, as we continue to develop pitchers at younger ages with year-round training. The typical patient is a high school or college-aged pitcher with insidious onset of medial elbow pain with pitching, losing velocity and unable to get back to where they were. At a younger age, we typically get more force through the growth plate rather than through the ligament, so fortunately or not, the ligament doesn’t get damaged at a younger age. Minimum age for me would have to be after growth plates are closed or close to it, which is around 15-16 in boys and this is typically because of the injury pattern itself, rather than a hard age cutoff. As to a maximum age cut off, obviously the older we get, the less demand we require to continue pitching or playing baseball, so late 30s or 40s, but age is a number, so really comes more to the demands of the player and what they need the elbow to do.
There are a lot of theories on the cause of the injury—velocity, overuse, the type of pitch being thrown, etc. You were a co-author on a 2016 study that suggested fastballs in particular contributed to Tommy John surgery. What makes it so damaging?
In the end, some of it makes perfect sense, and some doesn’t and it ends up being multi-factorial. Obviously, if you throw the ball at 99 mph, you don’t automatically get a UCL tear. But that high velocity definitely puts more stress through the elbow. In the end, think of it this way: the UCL ligament alone can withstand enough torque equivalent to an over 80 mph pitch at one time. Luckily the ligament isn’t all that holds the elbow together, the bones play a role and importantly the muscles around the elbow help stabilize the elbow as we throw. So, the more increased stress through the elbow with high velocity, the more everything else has to work. The more tired the muscles get (from overuse), the less they can protect the ligament from these higher stresses. The better mechanics we have with pitching to take that stress off the elbow, the better we can protect it. So, even though a curveball isn’t as fast, if we throw with improper mechanics, it still puts the elbow at risk.
In the end, it’s overuse, being constant stress through the elbow without allowing time to heal or protect the elbow and the increased stresses at the elbow, whether that is throwing the ball faster (fastball) or not throwing a curveball/slider, etc correctly.
As a high school coach, what can I do to reduce UCL injuries in my players?
The best way to reduce the risk of a UCL injury is with proper mechanics. There is a reason some MLB pitchers can pitch at such a high volume and high speed for so long without significant issues. Proper mechanics involve not only elbow exercises, but shoulder strength and stretching and most importantly core and lower body strength. Incorporating the whole kinetic chain into throwing takes undue stress off vulnerable areas. It is also important to rest a throwing arm. Many athletes today are pitching or playing year-round without any rest and although some pitch counts, etc. are in place, this usually isn’t enough. We know we get changes to the UCL (increased thickness, laxity and even calcifications) throughout a season and often with rest, these can resolve. I commonly recommend at least two months off of complete baseball rest a year. This can include playing other sports during that time but taking at least that two months can do a lot to prevent injuries in the long run.
The surgery is essentially the same as it was when it was invented, is anything being done to update or replace the surgery?
The concept of the surgery has remained constant, but the techniques have evolved over the years. When first started, the technique was to completely take down the flexor muscles to reconstruct the ligament and transpose the ulnar nerve in every case, as well as loop the tendon around and tie over itself for fixation. Now, we use a muscle splitting technique and treat the nerve on a patient-to-patient basis. The most common fixation method now is to dock the tendon in bone tunnels and then tie tightly over the bone bridge for the tunnels.
More recent advances have focused on tunnel placement and the proper location for tunnels, the same way we think of an ACL reconstruction. Tunnel placement in UCL reconstruction is important as moving the humeral tunnel even a few millimeters from the proper position can lead to increased stress as we return to throwing. So, more recent advances or emphasis has been on placing the tunnels in the correct spot and identifying this correct spot. Another more recent advancement has been in looking to repair the ligament rather than to completely reconstruct the ligament. This has shown promising results as it allows us to use your own tissue and the overall recovery is closer to four months, rather than a year. Unfortunately, this is not a treatment for all tears, as it requires a viable ligament left to repair and certain characteristics of the tear make it successful in certain situations.
Dr. Marshall has offices in Rochester and Shelby Township. For more information, visit his website.
Scott Bolohan is the founder of The Twin Bill. Dr. Marshall performed Tommy John surgery on my right elbow on February 19, 2021.