Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players

Variable Return to Play and Sport Performance After Elbow Ulnar Collateral Ligament Reconstruction in Baseball Players: A Systematic Review

PURPOSE

To evaluate return to play (RTP) and return to same level of play (RTSP) rates as well as preoperative and postoperative in-game performance metrics in baseball pitchers who underwent ulnar collateral ligament reconstruction (UCLR). Secondarily, this review sought to assess outcomes based on primary versus revision UCLR as well as level of competition.

METHODS

This review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane Database of Systematic Reviews were queried to identify articles evaluating UCLR in baseball players between January 2002 and October 2022. Data included RTP, RTSP, and performance metrics including earned run average, innings pitched, walks and hits per inning pitched, batting average against, strikeouts per 9 innings, walks per 9 innings, percentage of fastballs thrown, and average fastball velocity. The Methodological Index for Non-randomized Studies criteria were used for quality assessment.

RESULTS

Analysis included 25 articles reporting on 2,100 elbows. After primary UCLR, RTP ranged from 336 to 615 days (57% to 100% achieved) and RTSP ranged from 330 to 513 days (61% to 95%). After revision UCLR, RTP ranged from 381 to 631 days (67% to 98%) and RTSP ranged from 518 to 575 days (42% to 78%). When stratifying primary UCLR outcomes by competitive level, RTP and RTSP ranged respectively from 417 to 615 days (75% to 100%) and 513 days (73% to 87%) for Major League Baseball only, 409 to 615 days (57% to 100%) and 470 to 513 days (61% to 95%) for Major League Baseball plus Minor League Baseball, and 336 to 516 days (73% to 85%) and 330 days (55% to 74%) for college plus high school. Heterogeneity was seen in postoperative sports performance metrics.

CONCLUSIONS

Although more than half of baseball players appear able to RTP after primary and revision UCLR, RTSP rates after revision UCLR were as low as 42% in the literature. Preoperative and postoperative performance metrics varied.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years

CONTEXT

Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management.

OBJECTIVE

This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation.

DATA SOURCES

Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022.

STUDY SELECTION

Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing.

RESULTS

Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores.

CONCLUSION

Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.

Twisting technique for ulnar collateral ligament reconstruction of the elbow: new possibilities toward enhancing the strength of autografts

Background

Although the ulnar collateral ligament reconstruction procedure has been increasing in popularity annually owing to its stable postoperative outcomes, the number of revision surgeries following ulnar collateral ligament reconstruction has increased. The success of the initial reconstruction surgery and further improvement in the return-to-play rates of the initial surgery are crucial. In this study, we report on ulnar collateral ligament reconstruction using the twisting technique, which aims to enhance the strength of the graft (palmaris longus tendon) to improve return-to-play rates.

Methods

We investigated the return-to-play rate and period in 60 cases (2016-2021) that underwent ulnar collateral ligament reconstruction using the twisting technique and 211 cases (2007-2019) that did not use the twisting technique. The twisting technique involved inserting the graft through the bone tunnel and then twisting the doubled tendon.

Results

According to the Conway-Jobe scale, the twisting technique group had 98.3% excellent, 1.7% good, 0% fair, and 0% poor results, with a mean return-to-play period of 9.8 months. The non-twisting technique group had 86.7% excellent, 9.0% good, 1.9% fair, and 2.4% poor results, with a mean return-to-play period of 11.4 months. The two groups showed significant differences in return-to-play rate (P = .020) and period (P = .022).

Conclusion

The clinical results of the twisting technique showed that the return-to-play rate of the twisting technique group was higher after than before the procedure, and the return-to-play period was shortened by more than 1 month. The twisting technique may improve the results of ulnar collateral ligament reconstruction surgery.

Upper-Extremity Injuries Have the Poorest Return to Play and Most Time Lost in Professional Baseball: A Systematic Review of Injuries in Major League Baseball

PURPOSE

To summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines across 3 databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active Major League Baseball (MLB) athletes and studies published in the English language. Exclusion criteria were non-MLB players, case series and case report studies with a cohort of ≤3 players, and/or review articles.

RESULTS

A total of 477 articles were identified from the initial search of 3 databases, with 105 studies meeting inclusion criteria. Among these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the greatest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament (UCL) tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40%-72.5%), rotator cuff tears (33.3%-87%), and UCL tears (51%-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated nonoperatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days), and anterior cruciate ligament (ACL) tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement requiring arthroscopy, athletes had a significantly lower workloads compared with before injury upon return to play.

CONCLUSIONS

Most published investigations focus on elbow injuries of the UCL, with variable return to play and mixed performance following surgery. UCL tears, shoulder labral tears, and ACL tears result in the most missed time. Upper-extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest return to play rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for femoroacetabular impingement.

LEVEL OF EVIDENCE

IV, systematic review of level II-IV studies.

The Effect of the Crow Hop on Elbow Stress During an Interval Throwing Program

BACKGROUND

Postoperative rehabilitation protocols after ulnar collateral ligament (UCL) reconstruction typically involve a structured interval throwing program. In an effort to minimize torque placed on the UCL, athletes are often instructed to throw with a crow hop, even at short throwing distances. However, the effect of the crow hop on medial elbow stress is unknown.

PURPOSE/HYPOTHESIS

The purpose was to determine whether elbow stress differs with and without a crow hop across the throwing distances of a typical interval throwing program. We hypothesized that crow hop throws would generate lower torque on the elbow than standing throws at each distance of the interval throwing program.

STUDY DESIGN

Controlled laboratory study.

METHODS

Healthy high school and collegiate pitchers and position players were recruited from the surrounding area. Each player was outfitted with a wearable athletic sleeve and device that recorded elbow torque (Newton-meters), arm slot (degrees), arm speed (revolutions per minute), and shoulder rotation (degrees). Ball velocity (miles per hour) was measured using a radar gun. Players were instructed to perform 3 crow hop throws and 3 standing throws at distances of 30, 45, 60, 90, 120, 150, and 180 feet. A repeated measures analysis of variance was used to compare ball velocity, elbow torque, arm slot, arm speed, and shoulder rotation between crow hop and standing throws at each throwing distance.

RESULTS

Twenty athletes participated in this study (average age, 17.8 years; range, 15-25 years). The average medial elbow torque increased at each distance for both crow hop and standing throws at distances of 30, 45, 60, and 90 feet (P < .05), after which there were no significant increases in elbow torque (P > .05). The average torque was higher for crow hop throws than standing throws at distances of 30 feet (13.9 N·m vs 12.0 N·m; P = .002), 45 feet (21.8 N·m vs 19.3 N·m; P = .005), and 60 feet (28.0 N·m vs 24.5 N·m; P = .02).

CONCLUSION

Crow hop throws generated greater medial elbow torque than standing throws at distances up to 60 feet; however, there were no differences in elbow torque at distances greater than 60 feet between the 2 throw types. For both crow hop and standing throws, elbow stress increased at each distance interval up to 90 feet before plateauing at distances greater than 90 feet. The crow hop throwing technique does not reduce medial elbow stress during a simulated interval throwing program, and it may actually increase torque at shorter throwing distances.

CLINICAL RELEVANCE

The results of our study indicate that it would be prudent for players to initially perform standing throws at shorter distances and only later be allowed to employ a natural crow hop at greater distances to minimize torque placed on the medial elbow during UCL rehabilitation protocols.

Return-to-Play and Competitive Outcomes After Ulnar Collateral Ligament Reconstruction Among Baseball Players: A Systematic Review

Background:

Ulnar collateral ligament (UCL) reconstruction (UCLR) is very common in baseball. However, no review has compared the return-to-play (RTP) and in-game performance statistics of pitchers after primary and revision UCLR as well as of position players after UCLR.

Purpose:

To review, synthesize, and evaluate the published literature on outcomes after UCLR in baseball players to determine RTP and competitive outcomes among various populations of baseball players.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search including studies between 1980 and November 4, 2019, was conducted for articles that included the following terms: ulnar collateral ligament, elbow, medial collateral ligament, Tommy John surgery, throwing athletes, baseball pitchers, biomechanics, and performance. To be included, studies must have evaluated baseball players at any level who underwent UCLR (primary or revision) and assessed RTP and/or competitive outcomes.

Results:

A total of 29 studies with relatively high methodological quality met the inclusion criteria. After primary UCLR, Major League Baseball (MLB) pitchers returned to play in 80% to 97% of cases in approximately 12 months; however, return to the same level of play (RTSP) was less frequent and took longer, with 67% to 87% of MLB pitchers returning in about 15 months. RTP rates for MLB pitchers after revision UCLR were slightly lower, ranging from 77% to 85%, while RTSP rates ranged from 55% to 78%. RTP rates for catchers (59%-80%) were generally lower than RTP rates for infielders (76%) and outfielders (89%). All studies found a decrease in pitching workloads after UCLR. Fastball usage may also decrease after UCLR. Changes in earned run average and walks plus hits per inning pitched were inconclusive.

Conclusion:

Pitchers returned to play after UCLR in approximately 12 months and generally took longer to return to their same level of play. Pitchers also returned to play less frequently after revision UCLR. After both primary and revision UCLR, professional pitchers experienced decreased workloads and potentially decreased fastball usage as well. Catchers may RTP after UCLR less frequently than pitchers, infielders, and outfielders possibly because of the frequency of throwing in the position. These results will help guide clinical decision making and patient education when treating UCL tears in baseball players.

No change in performance metrics in major league baseball players sustaining wrist fractures after being struck by an errant pitch

Objective

This study aimed to determine the effect of wrist fractures on performance metrics in Major League Baseball Players after they were hit by an errant pitch.

Methods

Players who sustained wrist fractures after being struck by a pitch were identified and changes in performance metrics were calculated.

Results

In both the short- and medium-term analysis, there were no significant differences in all pre- and post-injury offensive statistics following return to play.

Conclusion

Wrist fractures sustained after being struck by an errant pitch do not significantly impact professional baseball player performance if the player is able to return to sport.

Outcomes Associated with Return to Sports Following Osteochondral Allograft Transplant in the Knee: a Scoping Review

PURPOSE OF REVIEW

The purposes of this review were to report the currently validated outcomes for OCA transplant patients, discuss the benefits and challenges associated with "return to sports" as an outcome measure, and summarize the currently available data on patients' ability to return to sports after OCA transplant.

RECENT FINDINGS

College athletes may take less time than professionals to return to basketball, but there are many factors that can influence this timeframe. Player productivity is decreased ~ 40% and future career length is only 1 to 2 years following return to play. When evaluating all OCA transplant patients, 75-88% of patients return to sport and 38-80% return to their previous level of play at approximately 8-10 months following surgery. Overall graft failure rates are low (0-9.4%) but are based on limited short- to medium-term data. Data on the return to professional and college sports after OCA transplant is limited. Surgeons should consider collecting patient outcomes across multiple domains and contributing data to aggregate databases to allow for better quality outcome data to be reported.

Prognostic utility of an magnetic resonance imaging-based classification for operative versus nonoperative management of ulnar collateral ligament tears: one-year follow-up

BACKGROUND

A recently introduced classification of medial ulnar collateral ligament (UCL) tears has demonstrated high interobserver and intraobserver reliability, but little is known about its prognostic utility. The purpose of this study was to assess the relationship of the magnetic resonance imaging (MRI)-based classification system and nonoperative vs. operative management. Secondary objectives included subanalysis of baseball players.

METHODS

Eighty-five consecutive patients with UCL tears after a standardized treatment paradigm were categorized as operative vs. nonoperative. UCL tears of patients with a minimum of 1-year follow-up were retrospectively classified using the MRI-based classification system. Subanalyses for baseball players included return-to-play and return-to-prior performance.

RESULTS

A total of 80 patients (62 baseball players, 54 pitchers) met inclusion criteria. A total of 51 patients underwent surgery, and 29 patients completed nonoperative management. In baseball players, 59% of the proximal tears were treated nonoperatively and 97% of the distal tears were treated operatively; 100% of the proximal partial-thickness tears and 100% of the distal complete tears were treated nonoperatively and operatively, respectively. Patients with distal (odds ratio: 48.4, P < .0001) and complete (odds ratio: 5.0, P = .004) tears were more likely to undergo surgery. Baseball players, regardless of position, were determinants of operative management, and there was no difference in return-to-play clearance and return-to-prior performance between the operative and nonoperative groups.

CONCLUSION

A reliable 6-stage MRI-based classification addressing UCL tear grade and location may confer decision making between operative and nonoperative management. Complete and distal tears carry a markedly increased risk of failing nonoperative care compared with proximal, partial tears.

Clinical Utility of an MRI-Based Classification System for Operative Versus Nonoperative Management of Ulnar Collateral Ligament Tears: A 2-Year Follow-up Study

Background

A recently introduced classification system of medial ulnar collateral ligament (UCL) tears accounting for location and severity has demonstrated high interobserver and intraobserver reliability, but little is known about its clinical utility.

Purpose

The primary purpose of this study was to assess the relationship of the magnetic resonance imaging (MRI)-based classification system in predicting which athletes had success with nonoperative versus operative treatment after completing a standardized rehabilitation program. A secondary objective included return to play (RTP) and return to prior performance (RPP) analyses of baseball players.

Study Design

Cohort study; Level of evidence, 3.

Methods

After an a priori power analysis, 58 consecutive patients with UCL tears and a minimum of 2-year follow-up were retrospectively divided into 2 groups: those who successfully completed operative treatment and those who completed nonoperative treatment. The MRI-based classification stages accounting for UCL tear location and severity were compared between the nonoperative and operative groups. A subanalysis for baseball players, including RTP and RPP, was performed.

Results

A total of 58 patients (40 baseball players [34 pitchers]) met inclusion criteria. Of these patients 35 (32 baseball players [27 pitchers]) underwent surgery, and 23 (8 baseball players [7 pitchers]) underwent nonoperative management. No patients in the nonoperative arm crossed over to surgery after completing the rehabilitation program. Patients with distal tears (odds ratio, 48.0; P = .0004) and complete tears (odds ratio, 5.4; P = .004) were more likely to undergo surgery. Baseball players, regardless of position, were confounding determinants of operative management, although there was no difference in RTP and RPP between treatment arms.

Conclusion

A 6-stage MRI-based classification system addressing UCL tear location and severity may help early decision making, as patients likely to fail nonoperative treatment have complete, distal tears, whereas those with proximal, partial tears may be more amenable to nonoperative management.

Return to Play Among Elite Basketball Players After Osteochondral Allograft Transplantation of Full-Thickness Cartilage Lesions

Background:

Osteochondral allograft transplantation (OCA) is a recognized option for full-thickness articular cartilage defects of the knee, especially in the setting of large lesions or those involving the subchondral bone. Previous heterogenous studies of athletes have shown a 75% to 79% rate of return to play after the procedure.

Purpose:

To define return-to-play rates in a cohort of elite collegiate and professional basketball players following osteochondral allograft of the knee.

Study Design:

Case series; Level of evidence, 4.

Methods:

Prospectively collected data from an institutional cartilage repair registry were retrospectively reviewed. Patients were eligible for inclusion if they were collegiate or professional basketball players at the time of surgery. Patient demographics, lesion size and location, and surgical details were collected. Postoperative magnetic resonance imaging scans were scored with the OCAMRISS system. Time to return to play and pre- versus postoperative player performance were determined with publicly available internet resources.

Results:

Eleven athletes (4 professional, 7 collegiate) with a total of 14 treated lesions (1 to the medial femoral condyle, 6 to the lateral femoral condyle, 5 to the trochlea, and 2 to the patella) were eligible for study inclusion. Mean lesion size was 509 mm². All patients underwent OCA through an arthrotomy, with fresh grafts. The overall rate of return to play at the same level of competition was 80%. Median time to return to play was 14 months (range, 6-26 months). Among players with available statistics, there was no significant reduction in any performance category.

Conclusion:

OCA in elite basketball players results in an 80% return to previous level of competition, which is consistent with previous reports of athletes playing other sports. Osteochondral allografting is a reasonable option to consider for full-thickness cartilage lesions of the knee, even for elite jumping athletes.