SCIENCE / MEDICINE : MILLION DOLLAR MEDICINE : Step-by-step guide to the revolutionary new surgery that repaired arm of the Dodgers’prize pitcher, Orel Hershisher
Among the physiological gifts that have helped make Dodger Orel Hershiser one of baseball’s top pitchers is the ability to whip his arm forward with the force necessary to snap off a nearly unhittable curve ball.
But that same force, over more than 800 innings of major league ball, has so pounded and stretched the casing of Hershiser’s right shoulder joint that doctors believe pitches in recent games have pulled his upper arm bone partially out of the shoulder socket.
The problem became obvious April 25 when Hershiser’s celebrated control went haywire in the fifth inning against St. Louis. By the seventh inning’s end, he had allowed five runs on five hits and walked four batters.
Two days later the 31-year-old pitcher underwent surgery at Inglewood’s Centinela Hospital Medical Center to tighten the casing, or “capsule,” of his shoulder, a repair not unlike what a tailor might do to take in a pair of baggy trousers: sew in a pleat.
Hershiser’s capsule was so loose that the ball of the upper arm bone, called the humerus, was slipping over the front edge of the shoulder socket when he reared his arm back to deliver a pitch, according to Dodger medical director Dr. Frank W. Jobe, who performed the surgery. The protruding humeral ball, in turn, pounded on one of four tendons that form the rotator cuff of the shoulder. Jobe described this tendon as looking as if it had been beaten with a “hammer,” but there were only surface tears, and Jobe expects it to return to normal.
Jobe and his colleagues at the world-renowned Kerlan-Jobe Orthopaedic Clinic in Inglewood slit open the capsule at the front of Hershiser’s shoulder joint and tightened the capsule’s tough, fibrous tissue by overlapping and then stitching the incision’s edges into a doubly thick band. The surgical team further strengthened this key joint-stabilizing structure by anchoring the sutures in the bone of the shoulder socket, called the glenoid.
The procedure takes advantage of surgical techniques developed only in the last five years, as arthroscopy--a means of looking into the body with a tiny magnifying device--revealed new subtleties about the nature of shoulder instability.
Among them, according to Jobe, was the realization that rotator cuff tears could have an underlying cause, namely, a stretched capsule. So repairs often are needed in both areas for the shoulder to work properly. Many athletes in recent years have undergone rotator cuff repair, but in some cases it has been unsuccessful because the significance of the capsule was not known.
Although Jobe has performed the capsule operation more than 30 times, this is the first time it has been done on a major league pitcher. It remains to be seen whether the tightened capsule will remain so under the terrific stress of pitching.
Another benefit to Hershiser was the development in the last year of a new type of strong suturing material, each strand of which is equipped with a metal toggle bolt at one end to anchor it in tiny holes drilled into bone.
The surgeons were able to avoid cutting across tendons and muscles or disturbing their connections with the shoulder bones, structural traumas that almost certainly would have meant the end of Hershiser’s pitching career. And Jobe, whose international fame in mending athlete’s injuries began with his legendary 1974 reconstruction of pitcher Tommy John’s elbow, is optimistic.
“I think his chances of coming back are fairly good because we’ve got a real tight repair and we didn’t take any muscles down, and he’s already got his full range of motion back,” Jobe said in an interview Thursday, six days after the operation. He said Hershiser was able to begin light rehabilitation the day after surgery, and predicted the star right-hander could start tossing pitches in four months, working up to competitive pitching within a year.
Ironically, Hershiser was the athlete used as a model a year ago by researchers studying how to prevent pitching injuries. With computer and electronic studies of Hershiser’s body alignment, motion and muscle action during pitching, scientists at Centinela Hospital Medical Center’s biomechanics laboratory hoped to pinpoint the cause of problems in injured pitchers.
The extent of the damage, which came as a surprise even to Jobe, may have been masked by Hershiser’s excellent fitness. Because his shoulder muscles were so well-conditioned, Jobe thinks they could have been compensating for some time for the joint’s instability, hiding evidence of the injury even from Hershiser. The muscles probably saved Hershiser from greater shoulder damage by keeping the arm bone in the socket until later innings when Hershiser tired.
To understand what happened to Hershiser’s shoulder, it helps to know something about the structure, mobility and tolerances of this important joint:
Raise your right hand as if you were taking the presidential oath of office. Now pull your hand (elbow at 90 degrees) slightly back. You should feel pressure along a line from the edge of the armpit to about half way up the front of your shoulder. This is the ball of your humerus--the upper arm bone--pressing against the muscles, ligaments, tendons and other connective tissues that hold it in the shoulder socket.
The shoulder socket holds the ball of the humerus in a very shallow cup compared to the hip socket. This is because the shoulder is built more for mobility than stability, allowing a full 360 degree rotation of the arm, which the hip joint would never permit the leg.
So the shoulder’s stability comes less from bone than from the interplay of softer tissues working to keep the arm centered in the socket. Among these are the scapular rotators, muscles that work to keep the socket positioned so that it forms a stable platform for the humerus. Jobe likens this action to the constant motion of a circus seal balancing a stick on its nose.
The second stabilizing tissue structure is the rotator cuff, where the tendons of the four main shoulder muscles come together. This ropey layer is responsible for holding the humeral ball in the shoulder socket. A tear or other damage to these tendons is one of the most dreaded of pitching injuries, and has ended many careers.
The third structure, which is fairly rigid, is the capsule, which encloses the bones of the joint like a cuff of leathery tissue crisscrossed by thicker bands known as the capsular ligaments.
The capsule is what Hershiser’s seven years of major league pitching stretched until it no longer could keep the humeral ball from slipping part way out of the socket, Jobe says. Medically, the problem is called anterior subluxation. It set Hershiser up for serious rotator cuff injury, but Jobe believes the problem was caught in time, and that the cuff tendons have not been permanently damaged.
Repairs to the capsule and other interior structures of the shoulder have been surgically undertaken for more than 50 years, so Jobe’s method of pleating the excess capsular tissue is nothing new. The innovation in Hershiser’s operation is the route taken to the afflicted area.
Conventional shoulder surgery calls for cutting the subscapularis tendon and muscle away from the humerus so the socket can be laid open. But recovery requires the shoulder and arm to be immobilized for six weeks, and some damage is inevitable to nerves responsible for the arm’s position, sense and rhythm, Jobe says.
In a pitcher, these were consequences to be avoided. So using specially designed tools to retract intervening soft tissue and hold the humeral ball away from the socket, Jobe was able to avoid severing any connections between muscle, tendon and bone.
Only two cuts were made, in addition to the one necessary to tighten the capsule. The first was a five inch skin incision from the right armpit to about one third of the way up the front of Hershiser’s shoulder. The second cut split apart the subscapularis tendon, which connects to the muscle that pitchers use to bring the arm forward after the windup. Because the split was along the grain of the tendon fibers, Jobe says it will heal without loss of power or mobility to the shoulder.
In Hershiser’s case, Jobe lays blame on two factors: genetics and too much pitching. Hershiser, he says, has a very flexible body, which means his connective tissues have more elasticity than the average person’s. Flexibility generally is a good quality in athletics, but it also may have given Hershiser’s capsular tissues a greater tendency to stretch than another pitcher’s.
The second factor was the cumulative number of pitches Hershiser has thrown in his career. In each of the last three seasons, Hershiser has led the National League in innings pitched, and Jobe believes that pace was more than his body could tolerate.
Hershiser is known for his uncomplaining nature, but he admitted the day before the operation that his shoulder had felt stiff while throwing in February and early March. “But I thought it was something I could work out,” he said. “I thought as I got stronger it would get better and better.”
1. An incision is made in the shoulder joint’s capsule--leathery, fibrous tissue that was stretched by the force of Hershiser’s pitches. The shoulder blade is on the right and the upper arm bone, or humenus, is not the left.
2. The capsule opened, a drill is used to make tiney holes along the edge of the glenoid, the bone cup in which the ball or top of the humerus rests. A surgical retractor (left) pulls the humerus away from the work area.
3. Suture strands, equipped on one end with a metal toggle bolt, are threaded through the holes in the bone. The toggle bolts lock them in place on the underside.
4. The edges of the capsule incision are pulled tight, with the top flap overlapping the bottom one to take up excess capsular tissue and create a strengthening, doubly thick band in the area that has been pressed hardest by the ball of the humerus. Further strength is provided by stitches connecting the capsule to the glenoid. The dotted line indicates the edge of the under flap of the incision.
Source: Dr. Frank W. Jobe; Kerlin-Jobe Orthepaedic Clinic-Inglewood
