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Bigger Ben: A not-so-common elbow injury

Just two games into the 2019 NFL season, Ben Rothlisberger hurt his elbow on a deep throw to Juju Smith-Shuster. Roethlisberger had season-ending surgery to re-attach three torn flexor tendons in his right elbow. And up until last week, that was almost all we knew about his injury. Big Ben and the Steelers organization were uncharacteristically quiet about the details surrounding the injury, but many speculated Ben suffered the dreaded torn UCL or Ulnar Collateral Ligament in his elbow, which would require him to undergo the famous “Tommy John” surgery.

Luckily (or maybe not-so-lucky, depending on how you look at it) Big Ben did not tear his UCL, but instead according to him the past few days, he ruptured 3 flexor tendons at this elbow and underwent a reconstructive surgery (using a graft to attach the tendons of the muscle back to the elbow bone). "They sew through the tendon, and they reattach it to an anchor in your elbow," he said according to ESPN. However, the location of these tendons is basically the same spot as the UCL and these tendons partly have a similar function as the UCL, to stabilize the elbow joint during a throwing type motion. So Big Ben didn't have Tommy John surgery, but lets go ahead and say he had Tommy John-Lite (trademark***) surgery.

Now, i’m not his doctor but Big Ben states he had suffered elbow pain in that area for years, which is consistent with him previously suffering from Common Flexor Tendonitis or “Golfers elbow”

The common flexor tendon attaches to the medial epicondyle of the humerus (bony pointy part of the inside of your elbow).

It serves as the superficial attachment point for muscles of the front of the forearm: The Flexor carpi ulnaris, Palmaris longus, Flexor carpi radialis, Pronator teres and Flexor digitorum superficialis.

Medial epicondylitis, also known as “golfer's elbow,” is a common orthopaedic condition that typically results from overuse of those muscles mentioned above. Repetitive loading of the muscles responsible for wrist flexion and forearm pronation and movements that lead to stress on the inner elbow (like throwing a football or baseball aka Valgus Stress) leads to microtrauma and subsequent degeneration of the common flexor tendon and UCL. The flexor carpi ulnaris and flexor digitorum superficialis muscles of the forearm lay directly over the UCL ligament and have been shown to provide about 24% of the dynamic stability of the joint.

The common flexor tendon attaches just above the ulnar collateral ligament (UCL), and provides dynamic stability to the elbow. Overhead-throwing athletes who end up with this injury, end up having it because of gradual degeneration leading to the avulsion/rupture/complete tear (same thing) later on.

Physical Therapy

After the initial surgery, a patient is usually placed in a splint that is removed at 10 to 14 days; the patient is then transitioned to a hinged elbow brace that allows for range of motion as tolerated. Strengthening exercises are started at 6 to 8 weeks later, and then no restrictions at 3 to 4 months and a gradual strengthening followed by sport-related activity is followed after that. Where it currently stands, Roethlisberger is about 10 months out of surgery.

Roethlisberger has been throwing at the Steelers' training camp and said, "We've been working more than usual in the offseason in terms of throwing. I've put together a regime of two to three days per week of throwing for the last probably two months, if not longer than that. I think the plan is to kind of pitch-count, if you will, through training camp."

"I'm lighter than I've been in 13, 14 years," he said. "I feel strong, I feel healthy, I feel young, if you can feel young at this age.”

He even says he is feeling great and I believe him, I think he’s ready.

For my injury experts out there, you can see how this is a much easier recovery than from Tommy John, where that surgery consists of replacing the old torn UCL with a tendon from a different part of the body.

  • The first 4-6 weeks of that rehab process are focused on reducing pain and swelling, restoring motion, and starting basic exercises.

  • The next two months consist of building strength, mobility, and stability.  This involves shoulder program exercises and using tiny dumbbells, slowly progressing week to week, laying the foundation for more advanced exercises.

  • Pitchers return to throwing at 9-12 months following surgery, with veteran MLB pitchers being able to return in 10-11 months.

Outlook: What Other QBs with similar injuries have faced

"From what I've been told, it's never happened to a quarterback of this magnitude. I believe there was at least another quarterback that had one, maybe two torn off, but from what I understand, not three."

Roethlisberger here is talking about the great Hall of Famer Joe Montana.

He underwent surgery after initially attempting nonsurgical methods to heal. Setbacks after the surgery kept him off the field for the San Francisco 49ers until the latter stages of the 1992 season.

“I tore the pronator off the bone,” Montana once stated. “…I was back throwing later that year (in 1991), but there was a zing whenever I threw…”

“Every time I threw, one of the staples zinged against my ulnar nerve,” Montana recalled to USAToday.com. “I had no feeling in my ring finger or pinky finger, so I couldn’t grip the football. The nerve damage is what held me back. Hopefully, he won’t have to deal with that.”

Jake Delhomme is one of the few QBs to actually have Tommy John surgery, after an injury 3 games into the 2007 season.

Delhomme returned to the starting position for the 2008 season and had a great season, finishing the regular season 12-4. However, his career basically was never the same and had a horrible 2009 season. Luckily, he signed a 5-year extension worth $42.5 million, with a $20 million guarantee before the 2009 season.

Fantasy Football Implications

I expect Big Ben to be 100% this upcoming season. Jake Delhomme was able to bounce back and have a great year after Tommy John surgery. Joe Montana had a similar injury and was able to keep playing, and Big Ben has modern medicine on his side. He will be approximately 11 months out of surgery, with the best medical team and rehab staff money can buy. By week 1 of the season, there should be no limitations on what he can do, however don’t be surprised if you see a modified “pitch-count” and a very run heavy game-plan the first few weeks of the season, especially since there is no pre-season.

I think Big Ben will be a top 15 Fantasy QB and I expect JuJu to have a bounce back year too, however I don’t expect him to have the same type of numbers he had when AB was the #1 receiver and taking all the double coverage. If Big Ben and JuJu play all 16 games, I can see them both being Top 15 at their positions.

Dr. Regi Bastien, DPT, OCS, CSCS

  • Doctor of Physical Therapy

  • Board Certified Orthopedic Specialist

  • Certified Strength and Conditioning Specialist

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