On one hand, Red Sox chief baseball officer Chaim Bloom’s words carried a shock: The Red Sox cannot bank on a return of infielder Trevor Story in 2023. On the other hand, the fact that there’s any chance of Story contributing represents a dramatic change in the landscape of elbow surgery, offering a measure of hope that did not exist until 10 years ago.
On Monday, Story underwent an internal bracing of the ulnar collateral ligament in his right elbow. The procedure emerged as an alternative to Tommy John surgery a decade ago, but unlike that operation, it offers the Sox a legitimate possibility of having Story on the field at some point in the coming season.
Dr. Jeffrey Dugas of the Andrews Sports Medicine and Orthopaedic Center recalled a conversation with Dr. James Andrews a bit more than a decade ago regarding the Tommy John surgery performed on a patient who had relatively healthy tissue and a minor tear of the ulnar collateral ligament.
“Dr. Andrews said, ‘Jeff, I can’t believe we have to do this big operation for this tiny little injury,’ ” said Dugas. “We only had one hammer for every nail. We only had reconstruction.”
Tommy John surgery has been around since 1974, when the eponymous pitcher underwent a ligament reconstruction performed by Dr. Frank Jobe. The surgery to replace the ulnar collateral ligament — the “Tommy John ligament” — is now well-established. Holes are drilled in two bones, the humerus and ulna, and a tendon taken from a wrist or leg is grafted through those holes.
The recovery is long for a number of reasons, including the fact that a tendon has to undergo “ligamentization” — becoming rigid enough to support the movement of the elbow when throwing.
For decades, Tommy John surgery represented the only consistently effective procedure for ligament tears, and it sidelined players for 12-18 months. Attempts to repair the ligament rather than reconstructing it proved ineffective.
But around the time that Andrews wondered to Dugas whether there might be something beyond the single hammer-and-nail approach, Dr. Gordon Mackay in Scotland took advantage of technological innovations to develop a new procedure to treat torn ankle ligaments: the internal brace. Rather than creating a new ligament, Mackay attached two small plastic anchors to the bones, then used a super-tape between the anchors, running along the ligament to repair it.
With no need for the ligamentization of tendons, and without drilling holes in bones, the recovery time was cut dramatically. Dugas was convinced that for patients with healthy tissue and smaller tears of the UCL, an internal brace was stronger than the ligament.
“You’re lining up the fibers of the tape in line with the ligament; it’s right on top of the ligament,” Dugas said. “It’s another layer of very, very stable material to control the instability and control the stress on the now-repaired ligament. You’ve repaired the ligament and now you’ve augmented it.”
Dugas performed the first procedure on Aug. 8, 2013. The results have been excellent.
“What we found, the success rate of the internal brace is around 93-95 percent,” said Dr. Kevin Wilk, director of rehabilitative research at the American Sports Medicine Institute. “The odds of coming back are very high.”
And recovery time has been far faster. Pitcher Rich Hill, for instance, had a partially torn UCL in November 2019. Rather than having a second Tommy John surgery, he elected to have an internal brace. Just over seven months later, when teams convened after the COVID-19 shutdown to prepare for a compressed season, Hill was game-ready.
Story could follow an even more accelerated timetable, given that he’s a position player; he won’t have to tax his arm to the same extent as a pitcher and won’t face the challenge of re-establishing command and feel.
A normal timetable would have Story beginning a throwing program at 10-12 weeks, with a gradual buildup of both his swinging and throwing from there. A return to competition at the five- to six-month mark — a rehab assignment in extended spring training followed by a lengthy minor league assignment — would be expected, with readiness to play in the big leagues coming perhaps one month later.
“It’s one thing to say you’re going to go back and play at five months or six months, but can you really compete at the major league level?” said Wilk. “That takes some time from a batting standpoint and maybe doing a stint in the minor leagues.
“A guy who has it done now, the All-Star break would be a kind of classic timeline for a professional infielder. It would give them enough time to really hone their skills.”
Of course, other factors can enter the equation. Normal hiccups in a rehab progression, perhaps unrelated to the brace itself, can lengthen the timeline, something that Bloom surely had in mind when declining to offer an estimate for Story’s return. Dugas suggested that a position player might need six to nine months, a range that, in Story’s case, might mean anything from the All-Star break to an inability to play before October.
The results of the surgery have been consistent enough that it’s becoming more common. Dugas estimated that he’s gone from performing internal brace procedures on roughly 5 percent of ligament tears in 2017 to roughly 30-35 percent now, having employed it on 170-180 patients in 2022.
The fact that Dr. Keith Meister, the Rangers’ team physician, performed the procedure on Story was viewed by Dugas and Wilk as a promising first step.
“Keith is among the elite elbow surgeons in the country,” said Dugas.
“For the most part, this is pretty predictable, especially in a position player,” said Wilk. “The outcomes are very high [success] and very predictable as far as a time frame.”