“Structural damage.” Don’t you just love how specific the injury reports are when you’re trying to find out what’s wrong with your favorite player? This term was used to describe what was seen on pitcher Brian Wilson’s recent elbow MRI, after missing time last season and struggling with his velocity early already this season. I’ve read plenty of MRI interpretations by musculoskeletal radiologists – some very detailed, but some not – and I can promise you that none of them are that vague. A term like “structural damage” can open the doors to some speculation, but Wilson has become more vocal about his elbow problems over the last 24 hours. It’s pretty clear at this point what’s going on, but let me first explain the basics.

The ulnar collateral ligament (UCL) in the elbow is the critical structure that resists valgus stress in the elbow. When a pitcher is in the cocking phase of the pitch, this ligament is under a great deal of stress. Unfortunately, it’s often too much stress, especially in someone with bad pitching mechanics. The ligament weakens over time and eventually ruptures. The pitcher describes the feeling as a pop or tear, and there can be associated numbness and tingling in the 4th and 5th fingers, secondary to the close proximity of the ulnar nerve to the UCL. Unfortunately, the only proven treatment for this is a repair. The surgeon uses another ligament (usually the palmar ligament in the wrist or the hamstring) to reconstruct the UCL. This is what is known as Tommy John surgery, and Brian Wilson underwent this surgery already while pitching in college. The rehab after the surgery is long and tenuous, but fortunately most pitchers recover well and can return to throwing and pitching about 12-18 months after the procedure. However, pitching mechanics must be addressed, because continuing bad habits will set one up for another injury, if not the same injury again.

Regarding his MRI findings, which we can assume indicate another UCL injury, Wilson sounds upbeat about the injury, saying, “I’m doing fine. I’m not down at all. This is an opportunity for me to get a better arm. Why is that disappointing? I get to throw harder. I like it. I like my odds.” He is referring to the fact that pitchers feel stronger when they come back from Tommy John surgery. There is not much science to back that up, but the thought is that the pitcher’s velocity and control slowly diminish as the ligament weakens, so after it has been repaired, the pitching improves.

Unfortunately for Wilson, assuming he has torn his UCL again, is that the odds of a return after a second repair are not in his favor. In this article :http://www.usatoday.com/sports/baseball/2007-07-18-tommy-john_N.htm, Dr. James Andrews estimates the success of a second Tommy John surgery as 20%. In case you don’t know, Dr. Andrews is THE guy in orthopedics when it comes to UCL injuries, and Wilson plans on consulting with him soon.

Now, let’s assume that “structural damage” means a partial tear. Are there other options? Sure. I’d recommend PRP to start the healing process and see how he does over time. Maybe “structural damage” means injury to the cartilage of the bones in the elbow. He could consider a variety of injections to help with pain relief. Given the second and third hand information we get from the media, it’s difficult to say with 100% certainty whether or not Wilson will return to pitching. You have to give the guy credit for his positive outlook and respectable work ethic. However, in my humble opinion, it doesn’t look good. At least he’s got an endorsement deal. Yo quiero UCL?