Management of the Ulnar Nerve in Throwing Athletes

Prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers

BACKGROUND

Radiographic and physical examination findings of ulnar nerve instability have been recognized in overhead throwing athletes, despite the fact that some of these abnormalities may be asymptomatic and represent adaptive changes. While recommendations for screening and early detection have been made that can adversely impact an athletes' career, the presence of bilateral ulnar nerve subluxation and its relationship with medial elbow symptoms has not been characterized in professional overhead throwing athletes.

PURPOSE

To characterize the prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers.

METHODS

A cross-sectional observational analysis was conducted utilizing standardized ultrasonographic examinations of bilateral elbows in 91 consecutive professional baseball pitchers (median age, 22 years; range, 17-30 years). The relationship between ulnar nerve subluxation and ulnar nerve signs, symptoms, and provocative physical examination maneuvers was also investigated.

RESULTS

The prevalence of bilateral ulnar nerve subluxation was 26.4% (95% CI, 17.7%-36.7%; 24 of the 91 athletes). Thirty-five athletes (38.5%; 95% CI, 28.4%-49.2%) had subluxation in at least 1 elbow. No athletes with subluxation had positive ulnar nerve signs, symptoms, or provocative tests.

CONCLUSION

Ulnar nerve subluxation is common among professional pitchers, and is more often than not bilateral. In this population of athletes, ulnar nerve subluxation does not appear to be associated with pathological findings.

Relationship between Medial Elbow Pain, Flexor Pronator Muscles, and the Ulnar Nerve in Baseball Players Using Ultrasonography

We aimed to clarify changes cross-sectional area (CSA) in flexor pronator muscles and the ulnar nerve (UN) in players with medial elbow pain between pitching phases. Forty-two male baseball players with and without medial elbow pain during throwing were included in this study. The players were divided into maximum external rotation (MER) and ball release (BR) groups according to the pitching phase in which pain was reported. The imaged region was the flexor digital profundus, flexor carpi ulnaris (FCU), flexor digitorum superficialis, and pronator teres muscles, as well as the UN. CSA at rest and during contraction was assessed using the ultrasonography software tracing function. For statistical analysis, the CSA at rest and at contraction in the healthy group, MER group and BR group was compared using one-way analysis of variance. There was a significant difference in CSA only in the FCU between the healthy (95.4 ± 15.5%) and the MER group (76.6 ± 12.5%) at rest (p = 0.004). There were significant differences in the UN between the healthy (105.0 ± 27.7%) and MER groups (176.4 ± 53.5%), and between the healthy and BR groups (132.9±21.1%) (p = 0.001 and p = 0.038, respectively). Our results suggest that athletes with medial elbow pain during the MER of pitching have ulnar nerve swelling.

Combining Cylindrical Bone Graft and Headless Screw Fixation for Nonunion of the Medial Trochlea of the Elbow: A Case Report

CASE

A 19-year-old handballer presented with elbow pain and nonunion of the medial trochlea of the elbow. He had undergone earlier surgery for an elbow injury at 6 years of age. Revision surgery for nonunion was performed using an extra-articular method combining cylindrical bone graft and headless screw fixation. Partial union was observed, and he resumed sports after 3 months, with his limb largely pain-free and functional. At the 21-month follow-up, bone healing was complete.

CONCLUSIONS

Combining cylindrical bone graft and headless screw fixation using the extra-articular technique is an option for managing nonunion of the medial trochlea of the elbow.

A Review of Upper Extremity Peripheral Nerve Injuries in Throwing Athletes

Peripheral nerve injuries in the upper extremities may be common in throwing athletes as the throwing motion places extreme stress on the dominant arm. The combination of extreme stress along with repetitive microtrauma from throwing uniquely places the throwing athlete at elevated risk of upper extremity peripheral nerve injury. However, because symptoms can be non-specific and frequent co-exist with pathology in the upper extremity, the diagnosis of peripheral nerve injury is often delayed. Diagnosis of peripheral nerve injuries may require a combination of history and physical exam, diagnostic imaging, electrodiagnostic testing, and diagnostic ultrasound guided injections. The primary management should include physical therapy focusing on throwing mechanics and kinetic chain evaluation. However, some athletes require surgical intervention if symptoms do not improve with conservative management. The purpose of this focused narrative review is to highlight upper extremity peripheral neuropathies reported in throwing athletes and to provide an overview of the appropriate clinical diagnosis and management of the throwing athlete with a peripheral nerve injury. This article is protected by copyright. All rights reserved.

Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition

Background:

Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis.

Purpose:

To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis.

Study Design:

Case series; Level of evidence, 4.

Methods:

Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire.

Results:

Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively.

Conclusion:

This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Return to play rates after ulnar nerve transposition and decompression surgery: a retrospective analysis

Background

Medial elbow pain is a common complaint in overhead throwing athletes. The throwing motion places repetitive tensile and compressive forces on the elbow resulting in significant stress across the ulnohumeral joint. This stress can result in soft-tissue, ligamentous, and ulnar nerve injury. The purpose of this study was to retrospectively investigate the clinical findings and outcomes, including return to play rates, of patients who underwent ulnar nerve transposition surgery for isolated ulnar neuritis.

Methods

Throwing athletes who underwent isolated, primary ulnar nerve transposition surgery over an eight-year period, 2009 to 2017, were identified and included in our analysis. Nonthrowing athletes, those who underwent revision ulnar nerve transposition surgery, and those who underwent concomitant ulnar collateral ligament reconstruction or repair were excluded. Patients were contacted to complete the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score as well as a return to play rate questionnaire. The minimum follow-up was 2 years.

Results

Fifteen patients met the inclusion criteria: 13 (86.7%) men and 2 (13.3%) women. The average age at the time of surgery was 19.2 years old (range, 15.6-28.0). Preoperatively, 13 (86.7%) patients played baseball and 2 (13.3%) patients played softball. Two patients (13.3%) underwent a previous ulnar collateral ligament reconstruction. There were no complications. The average final follow-up was 65.26 (range, 24.44-113.29) months with an average Kerlan-Jobe Orthopaedic Clinic Score of 64.51 (range, 28.60-100.00). Thirteen (86.7%) patients were able to return to their preinjury sport, 2 to a higher level of competition, 8 to the same level, and 3 to a lower level. Seven of the 13 (53.8%) patients sustained a postoperative ipsilateral shoulder or elbow injury at an average of 19.57 (range, 7.00-36.00) months postoperatively. All patients reported sustaining the injury as a result of throwing.

Conclusion

The results of our study indicate that ulnar nerve transposition surgery in throwing athletes allows athletes to return to throwing with low reoperation rates. However, more than half of the athletes in our analysis sustained a subsequent ipsilateral shoulder or elbow injury. Further investigation regarding outcomes in throwing athletes after ulnar nerve transposition surgery is warranted.