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A 33-year-old baseball pitcher with elbow pain
A 33-year-old right-handed minor league baseball pitcher who has been with four minor league organizations in his career presented after experiencing sudden onset medial elbow pain while pitching in a game. When the injury occurred, he felt a sharp “pop” while pitching in the early acceleration phase, tingling in the ulnar nerve distribution of his hand and an immediate inability to throw.
The tingling persisted for 1 day before resolving. He has been unable to throw since the injury. Prior to this injury, the patient noted occasional occurrences of medial elbow pain that resolved without treatment. Of note, the patient still has a desire to reach the majors leagues although he acknowledges that his likelihood of signing with a professional club has always been low.
Sanjeev Bhatia
Andrew R. Hsu
Examination
On examination, the patient’s right elbow was mildly swollen with no skin changes. Fluid was palpable in the soft triangle formed by the radial head, lateral epicondyle and tip of the olecranon. Point tenderness was only present over the ulnar collateral ligament. Range of motion testing demonstrated a mild flexion contraction about the elbow. He had a positive moving valgus stress test about the elbow as well as a positive milking maneuver test. Tinel’s testing at the cubital tunnel was negative and 2-point discrimination was intact at 5 mm in the thumb through small finger.
Figures 1a and 1b. Preoperative lateral view (a) and AP view (b) X-rays of the right elbow demonstrates the subtle degenerative changes.
Images: Bhatia S, Hsu AR
Imaging
Basic radiographic imaging demonstrated no acute fractures, dislocations or calcifications of the medial collateral ligament (Figures 1a and 1b). Subtle osteophytes were noted at the medial elbow joint line.
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Ulnar collateral ligament tear
The patient presented with pathology of his ulnar collateral ligament in his throwing elbow. Medial elbow complaints account for 97% of elbow complaints in pitchers. During throwing, the elbow is subjected to tremendous valgus stresses that are concentrated on the medial structures of the elbow, notably the ulnar collateral ligament (UCL). Although acute traumatic injuries of the ligamentous, musculotendinous and osseous structures of the medial elbow occur, repetitive chronic overuse injuries are far more common. In fact, up to 90% of UCL tears in throwers are acute-on-chronic injuries.
The ulnohumeral and radiocapitellar articulations provide close to 50% of the stability of the elbow, primarily against varus stress when the elbow is in full extension. The remainder of the elbow’s stability is owed to the UCL complex, the radial collateral ligament and the anterior capsule. The UCL complex is composed of three main bundles: anterior bundle, posterior bundle and oblique bundle. The anterior bundle is the most important for providing valgus stability to the elbow during throwing. This bundle consists of parallel fibers originating at the inferior aspect of the medial epicondyle that insert at the sublime tubercle on the medial coronoid process. The fibers are oriented such that they provide stability against valgus stress during the full range of elbow motion. The anterior bundle is further subdivided into an anterior band and a posterior band. From 0° to 90° of elbow flexion, the primary restraint to valgus stress is the anterior band of the anterior bundle of the anterior bundle whereas the posterior band of the anterior bundle takes on this role from 60° to full elbow flexion. The posterior band of the anterior bundle of the UCL is functionally more important in overhead athletes.
Charles A. Bush-Joseph
Repetitive valgus loading of the UCL in pitchers can lead to microtears of the ligament (primarily the anterior bundle) and subsequent attenuation. Such insufficiency in throwers results in medial instability and abnormal valgus rotation of the elbow. The abnormal mechanics that ensues is termed valgus extension overload and may result in increased contact pressure in the posteromedial aspect of the elbow, posterior medial and posterior impingement with wedging of the olecranon into the fossa during acceleration (and the subsequent development of osteophytes and loose bodies), and radiocapitellar cartilage injury.
Repetitive valgus loading of the UCL in pitchers can lead to microtears of the ligament (primarily the anterior bundle) and subsequent attenuation. Such insufficiency in throwers results in medial instability and abnormal valgus rotation of the elbow. The abnormal mechanics that ensues is termed valgus extension overload and may result in increased contact pressure in the posteromedial aspect of the elbow, posterior medial and posterior impingement with wedging of the olecranon into the fossa during acceleration (and the subsequent development of osteophytes and loose bodies), and radiocapitellar cartilage injury.
Diagnosis
In this case, suspicion was high for an UCL injury given the patient’s history and exam findings. Elements of the history that should be asked when assessing throwers with medial sided elbow pain include duration of symptoms, the phase of throwing that elicits pain, the location of pain, presence of ulnar nerve symptoms, and level of athlete’s performance and future goals. Physical examination of the elbow in throwers with medial sided pain should focus on discerning valgus instability when the elbow is flexed 20° to 30°. This maneuver maximally stresses the anterior band of the ulnar collateral ligament. To specifically test the competence of the posterior band of the anterior bundle of the UCL, an important structure in throwers, one can perform the milking maneuver; any apprehension or instability perceived is suggestive of UCL injury.
Figure 2. Preoperative MRI demonstrates
extensive edema of flexor pronator musculature
and UCL tear.
An MRI of the right elbow was ordered to help confirm the high suspicion of UCL injury. MRI demonstrated extensive edema of the flexor pronator musculature. The UCL was thickened and had a full thickness tear centrally (Figure 2).
UCL injuries in overhead throwers often result in difficult decision-making scenarios for the team physician because they juxtapose the player’s personal athletic goals with medical risks associated with conservative and surgical management. In general, a period of nonoperative treatment may be tried in most throwers with valgus instability of the elbow. Most conservative management regimens include a brief period of rest (2 weeks to 4 weeks) followed by stretching and strengthening of the dynamic stabilizers of the elbow, namely the flexor pronator mass. When instituted in the early stages of UCL insufficiency, nonoperative management may slow the progression of instability, and up to 50% of throwers may be able to return to their pre-injury level of performance.
Surgical intervention is reserved for the highly competitive overhead athlete who has an acute complete UCL rupture or chronic elbow UCL laxity for at least 3 months to 6 months. Surgical goals involve restoring elbow stability and returning the athlete to maximal functional levels. Typically, a surgical reconstruction is performed with either ipsilateral or contralateral palmaris longus autograft or a portion of the hamstring tendons. The ulnar nerve may or may not be decompressed concurrently at the time of surgery. Although surgery is frequently successful, it is not without risks. Complications involve potential injury to the medial antebrachial cutaneous and ulnar nerves.
The challenge of the team physician lies in providing realistic expectations of the success of the procedure, including the ability to return to throwing at or above the same level of performance that the athlete demonstrated before injury. In this example, the time-honored physician doctrine of “doing no harm” involves having a careful discussion with the patient regarding the ability of this surgical procedure to provide possibilities for returning back to high level pitching and reaching his ultimate goal of signing with a Major League Baseball club at the age of 33 years. The patient must be counseled appropriately about various risks, including the opportunity cost of being away from maximal functional performance for a period of 12 months to 18 months.
Follow-up
The patient was educated about his injury as well as the risks and benefits of UCL reconstruction. He still desired to play competitive baseball and felt his window of opportunity to play on a Major League Baseball club was not shut; thus, he elected for surgical reconstruction. He underwent a successful UCL reconstruction with palmaris autograft using a docking technique and an EndoButton (Smith & Nephew; Memphis, Tenn.). The cubital tunnel was released but the ulnar nerve was not transposed. He had no ulnar nerve symptoms after surgery. He initiated formal physical therapy at 4 weeks after surgery and will begin a light throwing program 4 months after his surgery. He may be ready to return to competitive baseball 9 months to 12 months after surgery.
Editor’s note:
The team physician does not determine the potential ability to return to sport.
References:
Jones KJ. J Bone Joint Surg Am. 2012;doi:10.2106/JBJS.K.01034.
For more information:
Bhatia can be emailed at sanjeevbhatia1@gmail.com.
Hsu can be emailed at andyhsu1@gmail.com.
Bush-Joseph can be emailed at cbj@rushortho.com.
Disclosures: Bhatia, Bush-Joseph and Hsu have no relevant financial disclosures.