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Panel discusses elbow UCL injury in throwing athletes

Issue: March 2015

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It is a privilege to serve as moderator for this Orthopedics Today Round Table discussion on elbow ulnar collateral ligament injuries. During the past year, tremendous attention to elbow ulnar collateral ligament (UCL) injuries has developed in response to the alarming number of well-recognized professional pitchers who have sustained UCL. In addition, it is now obvious that youth athletes are at disturbing risk for throwing-related injuries.

The goal of the discussion is to elicit expert opinion about the reasons for increased numbers of UCL injuries, elucidate the scope of the problem, understand prevention strategies, establish realistic expectations for nonoperative and operative treatment, and provide thoughts about the future.

Christopher S. Ahmad, MD
Moderator

Christopher S. Ahmad, MD: Do you consider ulnar collateral ligament (UCL) injuries an epidemic?

James R. Andrews, MD: I first started to notice this epidemic on the horizon back in 2000. At that point, I was only doing eight or nine Tommy John surgeries on high school players in 1 year. We have watched it steadily increase to the point that it is now as a matter of fact. Now, high school kids, when compared to all the groups including college, minor league and major league players, have the highest numbers. It has gotten to the point that our statistics show there has been a seven times to 10 times increase in Tommy John injuries at all levels since 2000. For me, this is certainly an epidemic, particularly at the youth level.

Michael G. Ciccotti, MD: The concern for a possible epidemic of UCL injuries is certainly appropriate given the media’s intense scrutiny of the number of UCL tears and subsequent UCL reconstructions in Major League Baseball (MLB) during the 2014 season. From 2000 through 2011, there was an average of 15.8 major league pitchers per year who underwent UCL reconstruction peaking at 20 in the 2007 season. In 2012, the number increased to 36, only then to drop back down to 19 in 2013.

The 2014 season noted a second dramatic increase in UCL injury and UCL reconstruction since 2000. A closer look at the 2014 season showed also an alarmingly high number of UCL injuries and surgeries early on from spring training through the first several months of the season as well as a peak of revision UCL surgeries. This sharp increase in UCL injury and surgery in the professional pitcher eerily parallels the sharp rise noted in incidence and surgery for the adolescent pitcher in the early 2000s. Some researchers have proposed that the injury leading to UCL reconstruction in today’s professional pitchers may be the result of excessive overuse begun as an adolescent pitcher.

Just as concerning as the overall number of UCL injuries and surgeries in MLB is the increasing incidence of recurrent UCL tears requiring revision UCL reconstruction. Recurrent UCL tears seem to be one of two types. The first type occurs in pitchers who have had an initial UCL reconstruction at a much earlier age and have been back competing for many years without issue. The second type occurs in players who are in the latter stages of their postoperative rehabilitation or who have just returned to competition.

The type 1 injury may most likely be merely a matter of probability; if you throw a significant amount for multiple years, you have an increasing probability of any one pitch injuring your reconstructed UCL. The type 2 injuries are harder to understand. These earlier postoperative recurrent injuries may be caused by any of a combination of factors such as 1) accelerated rehab which pushes the limits on biologic healing; 2) pitchers continuing pre-injury “at risk” pitching mechanics; and/or 3) that UCL reconstruction does not have a 100% success rate with 10% to 20% of athletes never returning to their pre-injury level of sport. Continued close observation of UCL injuries over the upcoming seasons will determine if this is a true epidemic. But whether the 2014 season classifies as an onset of epidemic proportion, this injury and the tremendous impact it has on any individual player, team and professional baseball necessitate continued close focus.

Neal S. ElAttrache, MD: At the professional level, there has been a steady but slight rise in the incidence of UCL reconstructions during the past 15 years. However, in 2 of the past 3 years, the number of reconstructions increased sharply. Of concern, is that a significant number of these were revisions. The number of primary reconstructions over this period was again only slightly up. At the professional level, we may be seeing an epidemic of revisions. In youth players, we have seen a significant increase in patients with UCL tears seeking reconstruction during the past 15 years.

Anthony A. Romeo, MD: There is a slight increase in professional athletes, but the epidemic of UCL injuries is present in youth athletes. In addition to Dr. Andrew’s personal experience, we have recently completed a study using a private payer database to look at the number of UCL procedures performed in the United States. There was a disproportionate increase in the adolescent population, which comprise more than 50% of patients who have this surgery.

Ahmad:What are the biggest risk factors for UCL injury in mature baseball players?

Stan Conte, PT, DPT, ATC: The following are the most likely risk factors to UCL injuries in the collegiate and professional baseball player:

• previous history of elbow injury;
• poor biomechanics;
• usage or over usage;
• MRI findings; and
• high-velocity throwing;

Risk factors in the collegiate and professional pitcher intuitively are thought to be similar to those of the immature youth pitcher. I say “intuitively” because although there are excellent studies in place for the youth risks, few if any studies have been done on the collegiate or professional pitchers that show a cause-and-effect relationship in perceived risk factors.

Youth studies including some excellent longitudinal studies have demonstrated a cause-and-effect relationship to arm injuries in youth pitchers with increasing game pitch count, innings per week and year and pitch type. However, in the mature pitcher, no such studies exist. Pitch counts have long been vilified, as the cause of shoulder and elbow problems, yet the decrease in extreme pitch counts in the past 15 years has not decreased the number of elbow injuries in professional baseball. The numbers have gone up. Even total innings per year have not been able to demonstrate a direct cause to increase in injuries in the pitcher, even though it makes logical sense to think it would.

Pitch type, especially the slider and curve ball, has been implicated in youth injuries but no evidence exists at the professional level. Many have tried to link the slider, split finger and sinker to increase injuries but no study to date has done so.

We know velocity has a direct mathematical relationship with stress on the UCL implying that a pitcher who throws 99 mph has an increased risk of tearing his ligament compared with a pitcher who throws 92 mph. We also know the average major league fastball was 90.8 mph in 2008. In 2013, it had reached 92 mph and eight pitchers hit triple digits. No study has shown yet that pitchers who throw harder get injured more often, even though intuitively we would say they should.

Once a player injures his elbow, typically, if not always, an MRI is performed to evaluate the ligament. Along with the physical exam, it is one of the definitive diagnostic tests to determine the extent of ligament damage. It is not uncommon to see significant changes in the ligament on a professional pitcher who has a normal, pain-free physical exam and continues to pitch without problems. Some physicians will refer to a MRI on an asymptomatic pitcher as “normal changes consistent with a pitcher.” Some pitchers seem to be able to pitch with what is considered an “insufficient ligament” that shows MRI changes and functional opening on testing.

Poor biomechanics have been implicated as one of the major risk factors in causing UCL injuries. There is little doubt that certain biomechanical flaws such as “dropping the elbow,” the inverted “W” wind up, and opening up the front side too soon increase the stress and torque on the UCL. Once again, no study has shown a direct relationship to these mechanics to injury.

All of these factors put increased stress on the UCL and have to be considered as potential risk factors. Just because no study has shown that, these factors have to be examined closely and mitigated whenever possible. However, all of this highlights the need for more studies into what factors or combination of factor are contributors to disability in the major league and collegiate pitcher.

To this end, MLB has formed research committees to try to study these. In 2015, MLB will undertake a 5-year prospective study in the minor leagues to look at this factor in newly drafted professional pitchers. They will get baseline MRIs, stress ultrasound studies, and biomechanical pitching evaluations as well as track usage before and after entering the professional ranks. Pitchers who injure their UCL will be compared to those who have not to determine predictive factors for future injury so prevention programs can be instituted. This may lead us to determine which risk factors are significant in the injuries to the UCL and be the foundation for specific-prevention programs.

Ahmad:What are the biggest risk factors for UCL injury in youth baseball players?

Andrews: Number one, a specialization that is playing youth baseball year-round. In our study of some 45 or 50 high school baseball players that I did a Tommy John procedure on, we found they averaged 1 week each year — the week between Christmas and New Year’s Day — where they were not throwing at a high level. The second risk factor is professionalism — that is overtraining youth baseball players as if they were adult professional players with pitching coaches and other aspects of daily baseball routines. The third risk factor is poor mechanics. Poor mechanics has a lot to do with the young baseball player not being able to throw a curve. The curveball is also a risk factor associated with mechanics. We recommend not throwing a curveball until they shave. That means they have gone through puberty and have good neuromuscular control to throw a more sophisticated neuromuscular controlled pitch, such as a curveball.

The next risk factor is showcases. Some showcases are good, and some are poorly organized. Kids go there thinking they are trying to impress a scout or high school or college coach. They may not be in shape, it may be in the middle of the winter or they may be coming off a minor injury. They may not be ready to throw, but they will throw at a high level, trying to overthrow, and will get hurt. The next factor is travel ball. The problem with travel ball is many times young athletes play in two leagues at the same time. The other problem is overthrowing at high velocity and the risk factor associated with that is the radar gun. I have recommended the radar gun be de-emphasized and maybe outlawed in youth and high school baseball, except for special situations.

Ciccotti: There is a rapidly growing amount of excellent research focused on UCL injuries in baseball players that applies to the youth or adolescent athlete. Though a variety of risk factors have been proposed, most medical professionals and researchers agree overuse is likely the biggest risk factor. Other risk factors include high velocity, poor pitching mechanics, inadequate conditioning and the use of various off-speed pitches. The overuse seen with lifelong throwing may predispose to injury of the UCL. Throwing so much, so early in life may cause a multitude of subtle, but physiologically significant changes in the UCL that cumulatively prevent or inhibit full biologic healing and weaken the ligament.

Pitchers, who are then throwing harder than ever, on a year-round basis and at an earlier age, add significant ongoing stress to an increasingly injured ligament. This increasing emphasis on year-round throwing and travel ball generates nearly fulltime participation by young, physically immature baseball players. Great efforts have been focused on developing schedules for pitch counts and limits on innings to prevent overuse. Yet despite these efforts, overuse of the youth or adolescent pitcher continues.

Velocity may also be a risk factor. We know throwing a baseball at high velocities (more than 85 mph) on any single pitch may exceed the tensile strength of the UCL. We see a heightened emphasis on velocity even with young, adolescent and teenage pitchers. This heightened focus places biomechanical forces through the UCL in athletes who have yet to fully develop the muscular balance throughout their upper extremity as well as the entire kinetic chain to withstand those forces with such high frequency.

It has been suggested that certain types of off-speed pitches may be a risk factor for elbow injuries in young pitchers. Dr. Ahmad’s recent systematic review of the injury risk of the curveball indicates that biomechanical and epidemiologic research has not clearly identified a correlation between off-speed pitches, such as curveball and elbow injuries in young athletes.

ElAttrache: I consider the biggest risk factors for UCL tears in youth players to be:

• overuse due to year-round participation on multiple teams;
• general as well as acute fatigue. Sleep deprivation (less than 8 hours per night for teenagers) plays a very big role;
• early specialization as a pitcher; and
• the ability to throw at velocities exceeding 85 mph before maturity.

Romeo: The current best available scientific evidence suggests that pitch counts, overall yearly pitching load, pitching for more than one team, pitch velocity, loss of rotational arc and pitching through fatigue or weakness are the most significant, reproducible risk factors. Fatigue that leads to or accentuates poor mechanics leaves the UCL unprotected during the throwing motion and subjects the ligament to forces that can cause it to tear. The guidelines offered by Little League Baseball and the recently developed MLB website, www.pitchsmart.com, focus on modifying these risk factors, as well as others such as type of pitch which has less support as a risk factor, in an effort to match the science with injury prevention strategies.

A note from the editors:

Read part two of this discussion in the April issue of Orthopedics Today.

For more information:

Christopher S. Ahmad, MD, can be reached at Columbia University, Center for Shoulder, Elbow and Sports Medicine, 622 W. 168th, New York, NY 10032; email: csa4@columbia.edu.
James R. Andrews, MD, can be reached at the Andrews Institute for Orthopaedics & Sports Medicine, 1040 Gulf Breeze Pkwy., Suite 203, Gulf Breeze, FL 32561; email: info@theandrewsinstitute.com.
Michael G. Ciccotti, MD, can be reached at the Rothman Institute, 925 Chestnut St., Philadelphia, PA 19107; email: deborah.bauer@rothmaninstitute.com.
Stan Conte, PT, DPT, ATC, can be reached at email: stanc@ladodgers.com.
Steve Donohue, ATC, can be reached at email: sdonohue@yankees.com.
Neal S. ElAttrache, MD, can be reached at Kerlan Jobe Orthopedic Clinic, 6801 Park Terr., Los Angeles, CA 90045; email: elattrache@aol.com.
Glenn S. Fleisig, PhD, can be reached at American Sports Medicine Institute, 2660 10th Ave. South, Suite 505, Birmingham, AL 35205; email: glennf@asmi.org.
Anthony A. Romeo, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612; email: anthony.romeo@rushortho.com.
A.J. Yenchak, DPT, can be reached at ColumbiaDoctors Midtown, 51 West 51st St., Suite: 370, New York, NY 10019; email: ay2270@cumc.columbia.edu.

Disclosures: Ahmad, Conte, Donohue, ElAttrache and Yenchak report no relevant financial disclosures. Andrews is a consultant for Biomet Sports Medicine, Bauerfiend, Theralase, MiMedx; is the medical director for Physiotherapy Associates; is a stockholder for Connective Orthopaedics and Patient Connection; and is a board member for Fast Health Corporation. Ciccotti Is a board or committee member for the American Orthopaedic Society for Sports Medicine, Major League Baseball Team Physicians Association, Herodicus Research Society; receives research support from Arthrex; is a paid consultant for Stryker; and has stock or stock options in Venture MD. Fleisig is a consultant for Motus Global; Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.