Return-to-Play Outcomes in Professional Baseball Players After Nonoperative Treatment of Incomplete Medial Ulnar Collateral Ligament Injuries: A Long-Term Follow-up Study

Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model-Based Analysis

BACKGROUND

Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown.

PURPOSE

To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional).

STUDY DESIGN

Economic and decision analysis; Level of evidence, 2.

METHODS

A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER).

RESULTS

The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers.

CONCLUSION

Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.

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.

Reinjury Following Return to Play

Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.

Rehabilitation of the painful elbow

Although lateral elbow pain and medial ulnar collateral ligament injury are common musculoskeletal pathologies in overhead athletes, the evidence supporting specific interventions for managing these conditions is scarce. Management of these conditions has been guided mostly by expert opinion rather than empirical evidence, yet the lack of comparative data in the literature has not negatively affected return-to-play rates following surgery. However, an understanding of what is known regarding unimodal and multimodal treatments for lateral elbow pain and medial ulnar collateral ligament injury is needed for clinicians to select evidence-based treatment pathways and highlight what is not known to develop future high-quality investigations.

Medial elbow injuries in the throwing athlete

There has been an epidemic increase in injuries to the elbow in our youth sports over the past 15 years. Initially, career-ending elbow injuries occurred almost exclusively in the professional population. The landmark procedure developed by Dr. Frank Jobe, colloquially termed "Tommy John surgery" after the initial player in whom he performed the surgical procedure, allowed roughly two-thirds of professional athletes to return to play at or near the same level. As the surgical procedure became more widespread, modifications of the technique by Jobe and many other contributors raised the return-to-play level to 85%-94% of players regaining the ability to return to sport at the preinjury level. Almost simultaneously, the emphasis on velocity in the professional ranks led to an unintentional increase in stress on the throwing elbow. This was magnified in our athletes by the advent of year-round sports, as well as the formation of "showcase" events to demonstrate skills and measure velocity. This, unfortunately, has resulted in an increase in both repetitive stress injuries and acute traumatic injuries in our young athletes. The purpose of this article is to discuss age-related injuries from both a preventative standpoint and a treatment standpoint.

Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis

BACKGROUND

Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear.

PURPOSE

To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries.

RESULTS

A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757).

CONCLUSION

For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.

Reliability of ulnar collateral ligament findings in magnetic resonance imaging

BACKGROUND

Ulnar collateral ligament (UCL) tears are common in baseball players. Although magnetic resonance imaging (MRI) is the most used imaging modality for UCL injuries, the inter-rater reliability of MRI analyzing specific characteristics of UCL pathology has not been defined. The purpose of this study was to define the inter-rater reliability of MRI for evaluating UCL characteristics.

METHODS

Three surgeons analyzed 45 noncontrast MRIs: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with intraoperatively confirmed full-thickness tears. Findings evaluated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcifications, and partial- or full-thickness tearing) and location of the pathology (proximal, midsubstance, or distal). Fleiss' κ coefficients were used to assess interobserver reliability.

RESULTS

There were high rates of agreement for midsubstance (κ: 0.50) and distal (κ: 0.69) ligament edema and proximal osseous edema (κ: 0.48). There were low rates of agreement for proximal ligament edema (κ: 0.08), ligament thickening (κ: -0.02 to 0.20), and proximal to midsubstance calcifications (κ: -0.04 to 0.10). Midsubstance (κ: 0.55) and distal full-thickness tears (κ: 0.63) demonstrated higher agreement than proximal (κ: 0.29). Proximal partial-thickness tears (κ: 0.45) had higher agreement than midsubstance (κ: -0.02) or distal (κ: -0.02).

CONCLUSIONS

In our study, there was high inter-rater reliability regarding proximal osseous edema, midsubstance, and distal ligament edema and full-thickness tears. There was no agreement for midsubstance and distal partial-thickness UCL tears, but fair agreement for proximal tears. UCL tissue characteristics including ligament thickening and calcifications demonstrated low agreement. Challenges remain in effectively evaluating UCL tissue characteristics on noncontrast MRIs.

In Vivo Effect of Partial Ulnar Collateral Ligament Tear Location on Ulnohumeral Joint Gapping With Stress Ultrasound in Baseball Pitchers

BACKGROUND

Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results.

PURPOSE/HYPOTHESIS

The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)-confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist.

RESULTS

Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P = .499).

CONCLUSION

No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.

Missing The Forest For The Trees: A Lack Of Upper Extremity Physical Performance Testing In Sports Physical Therapy

Background

Despite shoulder and elbow injuries being common in athletics, return to sport and reinjury rates are less than ideal. These outcomes may be driven by the absence of evidence-informed testing to determine an athlete's readiness for sport.

Purpose

The purpose of this study was to explore the reported frequency of physical performance testing for return to sport readiness by physical therapists treating athletes with upper extremity injuries and to identify potential barriers that may limit use of these tests. A secondary aim was to compare practice patterns of clinicians with sports physical therapy specialty certification to clinicians without.

Study Design

International, cross-sectional survey using purposive sampling.

Methods

A survey instrument was created to assess the frequency of use of physical performance tests by physical therapists treating athletes with upper extremity injuries, as well as the barriers limiting the use of these tests. The 19-question online survey was distributed via email and Twitter among sports physical therapists. Independent t-tests and Chi Square analyses were conducted to determine differences in practice patterns between physical therapists with and without specialization and the frequency of potential barriers that may limit the use of these tests.

Results

Four hundred ninety-eight participants met study eligibility and completed the survey. Fewer than half of participants reported using any physical performance test in making return to sport decisions for athletes with upper extremity injuries. The greatest barriers to the use of physical performance tests were a lack of equipment followed by lack of understanding of the literature, lack of time, and lack of supporting literature. Sports specialist clinicians were significantly more likely (p<0.001) to use physical performance tests than non-specialist clinicians (71.6% versus 36.3%).

Conclusion

In this survey of physical therapists (n=498), the majority admit to not using physical performance tests when making return to sport decisions for athletes with upper extremity injuries regardless of specialization.Physical therapists have an opportunity to improve the utilization physical performance testing in the upper extremity athlete in hopes of reducing injury recurrence and enhance return to sport rates.

Level of Evidence

Level 3b.

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.

Medial Ulnar Collateral Ligament Injuries in Contact Athletes

PURPOSE OF REVIEW

The purpose of this article is to review medial ulnar collateral ligament (UCL) injuries in contact athletes. UCL injuries in overhead throwing athletes are typically chronic attenuation due to repetitive valgus stress on the elbow during the throwing motion. As such, UCL reconstruction is commonly performed for these athletes. In contrast, UCL injuries in contact athletes are usually acute ligament tears or avulsions of a ligament with otherwise normal tissue. Nonoperative treatment is typically the first-line treatment for partial injuries. UCL repair may work well for acute complete injuries and may avoid the donor site morbidity of UCL reconstruction.

RECENT FINDINGS

Most of the literature regarding UCL injuries have been performed in baseball players. Historically, UCL repair has had poor outcomes in baseball players due to the chronic ligament attenuation. Therefore, much of the recent literature has focused on outcomes of UCL reconstruction, which are generally excellent. However, there is a paucity of literature studying outcomes of UCL injuries in contact athletes and those studying UCL repair. One recent study looked at a new technique for UCL repair with collagen-coated fiber tape augmentation in baseball players and found good short-term outcomes. UCL injuries in contact athletes occur typically as acute tears or avulsions. While UCL reconstruction has typically been recommended as the accepted treatment for UCL tears that require operative treatment, UCL repair may be a good alternative in contact athletes.

Using Advanced Data to Analyze the Impact of Injury on Performance of Major League Baseball Pitchers: A Narrative Review

Major league baseball (MLB) pitchers are at risk of numerous injuries during play, and there is an increasing focus on evaluating their performance in the context of injury. Historically, performance after return to play (RTP) from injury has focused on general descriptive statistics, such as innings or games played, or rate statistics with inherent variability (eg, earned run average, walks and hits per inning pitched, strikeouts per 9 innings, or walks per 9 innings). However, in recent years, MLB has incorporated advanced technology and tracking systems in every stadium, allowing for more in-depth analysis of pitcher-specific data that are captured with every pitch of every game. This technology allows for the ability to delve into the pitching performance on a basis that is more specific to each pitcher and allows for more in-depth analysis of different aspects of pitching performance. The purpose of this narrative review was to illustrate the current state of injury recording for professional baseball pitchers, highlight recent technological advances in MLB, and describe the advanced data available for analysis. We used advanced data in the literature to review the current state of performance analysis after RTP in MLB pitchers after injury. Finally, we strived to provide a framework for future studies to more meticulously assess RTP performance given the current available resources for analysis.

Outcomes After Medial Ulnar Collateral Ligament Graft Repair in Professional Baseball Pitchers With Minimum 2-Year Follow-up

Background

Rerupture of the reconstructed ulnar collateral ligament (UCL) is becoming more frequent at the professional level of baseball. However, there is no literature describing outcomes after UCL graft repair.

Purpose

To evaluate rerupture rate, return to play, performance upon return, and patient-reported outcomes after a novel UCL graft repair technique.

Study Design

Case series; Level of evidence, 4.

Methods

All included patients underwent UCL graft repair after a previous UCL reconstruction, pitched in at least 1 professional baseball game before repair, and were at least 2 years postprocedure within the same 10-year time period. The authors evaluated patient characteristics and performance metrics, including wins, losses, win percentage, earned run average, innings pitched, walks and hits per inning pitched, for the 2 seasons before and after the procedure. Patients were contacted to assess UCL rerupture, timing of return to sport, current level of competition, Conway score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score.

Results

Six players met the inclusion criteria. All had proximal UCL graft ruptures and underwent flexor-pronator tendon repair in combination with graft repair. At a mean (±SD) follow-up of 56.7 ± 37.8 months, no reruptures were encountered, and the mean KJOC score was 87.9 ± 14.6. Of the 6 pitchers who underwent UCL graft repair, 4 (67%) returned to professional pitching at a mean of 17 ± 6 months. Three of the 6 (50%) achieved an excellent Conway score, signifying a return to prior level of sport. There was no significant difference in demographic or preoperative pitching performance metrics between players who did and did not return to pitching. For those players who returned to professional pitching, there was no significant difference between preprocedure and postprocedure performance statistics.

Conclusion

Repair of the UCL graft appears to yield comparable rates of return to play and performance with revision UCL reconstruction. This technique serves as a viable alternative for proximal avulsion ruptures of the UCL graft.