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Panel discusses elbow UCL injury in throwing athletes, part 2

Issue: April 2015

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It is a privilege to serve as moderator for this discussion on elbow ulnar collateral ligament injuries, in which we detail treatment options for high school and professional pitchers with tears and the future of ulnar collateral ligament injuries. Click here to read part 1 of this discussion.

Christopher S. Ahmad, MD
Moderator

Ahmad:What has biomechanical analysis of pitching taught us about UCL injuries?

Glenn S. Fleisig, PhD: UCL injuries from baseball pitching have been a focus of biomechanical research for the past 20 years, long before the recent rash of high-profile injuries. The biomechanics has been divided into two types of research – motion studies of pitchers and mechanical studies of cadaveric elbow specimens. Comparison of the findings has led to an alarming conclusion: the tensile force on the UCL during the pitch of an elite pitcher is well above the tensile failure strength of the UCL of a cadaveric elbow.

Part of this discrepancy can be explained that the strength of a UCL from a deceased elderly male or female is less than that of a living young male elite athlete. Nevertheless, biomechanical research supports the notion that the UCL is stressed near its limit during a maximal effort pitch.

Biomechanical analysis of pitching also has correlated variations in pitching mechanics with increased elbow varus torque, and thereby increased UCL tensile force. For example, late shoulder external rotation, low shoulder abduction and excessive elbow flexion during pitching are some motions that may lead to increased elbow varus torque. Biomechanical analysis can reveal flaws in a pitcher’s mechanics that should be corrected to reduce injury risk and improve performance. The key for meaningful change are coaches. Biomechanical analysis can reveal dangerous flaws, but a coach works with a pitcher to fix the flaws.

Speaking about biomechanical analysis, there are some exciting changes in the field. Up until a few years ago, a pitcher had to come to a biomechanics lab to be analyzed. While this is still an excellent option, its impact is limited to those with the time and money to go to a lab. Companies like Motion Analysis Corporation, Vicon and Qualisys have improved their technologies so the camera and marker systems are no longer limited to indoor labs with controlled lighting. Instead of baseball pitchers coming to biomechanics labs, the labs can essentially come to the players. Another new technology is the Motus pitch sleeve. While this sleeve does not make full-body measurements, it is a portable technology to measure the biomechanical parameters most directly related to UCL injuries, such as elbow varus torque.

With these new outdoor technologies, MLB and the MLB Players Association have initiated scientific studies of pitching biomechanics and UCL injuries. The first such study by MLB was conducted during 2014 spring training in collaboration with several orthopedists and biomechanists. The study compared the biomechanics of professional pitchers with a history of UCL reconstruction with a control group of professional pitchers. Discussions are now underway for further studies of pitching biomechanics and UCL injuries in professional baseball.

Ahmad: What are the most important things we can do to prevent UCL injury in competitive pitchers?

Steve Donohue, ATC: A preventive approach with regards to UCL injuries is the most important thing we can do with regard to competitive pitchers. We must monitor pitchers for tightness, soreness or fatigue in the elbow/forearm complex. We also have to monitor innings pitched and times warmed up in the bullpen. Some teams measure stressful innings. With the assistance of our pitching coach, we monitor pitching mechanics and keep track of any changes in velocity. Early detection of any changes or tip offs of any kind of irregularities can help prevent major injury. We can adjust schedules whether that is skipping a side session between starts or skipping a start altogether or even spending time on the disabled list, while receiving treatment and taking some needed time to rest, and then proceeding through a slow progressive throwing program to ramp up to competition.

Another preventive measure we institute is a sound shoulder and arm care program that consists of both strength work for scapula/shoulder/arm and core scheduled in conjunction with their starts or relief appearances, as well as soft tissue work that our pitching staff maintains on regular basis. Another preventive factor we incorporate is in assessments at spring training is to test range of motion (ROM) and muscle testing to determine imbalances or weaknesses that could cause an issue. Follow-up assessments throughout the season can help determine any underlying issues as well.

A.J. Yenchak, DPT: It will be important to differentiate youth athletes from collegiate and professional athletes when addressing preventative measures for these types of injuries. From a youth perspective, we have definitive injury risk parameters for participation, frequency, volume and proper rest periods. The principles have been studied for decades by a brain trust of professionals who are now forming a team as part of MLB’s Pitch Smart initiative. These baseball commandments will serve as a decision-making blueprint for coaches, parents and health care professionals when formulating sport participation schedules, implementing throwing programs, enhancing exercise routines and devising more conservative rehabilitation protocols. This program will also help parents identify key ingredients within their child’s sports schedule that may be cause for participation modification.

As we move up the competitive ladder, health care professionals like me lose sleep thinking about intervention strategies to keep athletes on the diamond. The most important aspects of injury prevention from a clinical standpoint revert back to the fundamentals within the literature. Limb symmetry characteristic to the overhead athlete, strength ratios of the rotator cuff, and the identification of adaptations unique to the throwing athlete continue to drive my examination process when assessing collegiate and professional athletes. These specific characteristics continue to be studied and will continue to evolve so we can further delineate the more important risk factors that drive the substance behind our prevention programs.

Ahmad: How would you treat a 16-year-old high school sophomore pitcher with partial UCL tear?

Ciccotti: There is a spectrum of partial UCL injuries that range from minimal changes in the ligament to significant high-grade damage. My treatment recommendations would be based on a thorough exam of both elbows including ROM, strength, tenderness and stability testing (valgus stress, milking test, and dynamic milking test). Also a thorough examination of the ipsilateral shoulder, core and legs (kinetic chain) is carried out. Plain X-rays can be helpful to identify any type of avulsion injury of either the medial epicondyle of the humerus or the sublime tubercle of the ulna. Plain X-rays may also show chronic calcification within the substance of the ligament suggesting an acute-on-chronic injury. MRI or MR arthrography can be helpful to delineate partial, undersurface tears, but these are static tests.

We have utilized extensively SUS, which has been particularly helpful in partial injuries of the UCL. We have published research documenting the ability of SUS in a cadaveric model to identify increasing laxity with increasing damage to the various components of the UCL complex as well as the flexor pronator mass. We have also published a prospective, 10-year longitudinal, clinical SUS study on elite baseball pitchers, documenting the changes seen with SUS in asymptomatic pitchers as well as comparing those athletes with a UCL injury to their uninjured elbow and to those uninjured athletes. Our findings suggest that laxity of approximately 1.5 mm to 2 mm with and without stress may indicate a higher degree of UCL damage. This amount of stress laxity has strongly suggested that nonoperative treatment may not be successful, and that operative UCL reconstruction may be necessary.

In the high school athlete with a partial UCL injury which is stable on SUS, my initial treatment would be a nonoperative program. This includes a period of rest from throwing for upwards of 6 weeks. During that time, ice and heat contrast with modalities as well as a short course of anti-inflammatories can help to ease inflammation. A progressive ROM program in addition to strengthening of the upper extremity musculature most specifically the flexor pronator mass is carried out. Special attention is directed to the entire kinetic change to optimize flexibility and strength. At approximately 6 weeks, a return to play throwing program is initiated which includes a short toss/long toss program in which athletes play catch over an increasing distance. Once reaching a set distance (i.e., upwards of 180 feet), a pitcher then begins a throwing program. This throwing program includes throwing fastballs first with increasing effort followed by off-speed pitches, bullpens, simulated games or rehab games before returning to competition. More recently research has evaluated the potential benefit of biologic treatments (i.e., platelet rich plasma [PRP] or stem cells) for partial injury to the ulnar collateral ligament. Podesta and colleagues have documented possible benefit in these partial injuries with PRP use. Further research is necessary to substantiate the broad use of these biologic treatments for such partial injuries.

ElAttrache: I would treat with rest from throwing for 6 weeks followed by a 6-week progressive throwing program if pain free. Increasingly, an attempt to biologically augment healing with PRP injections is performed during the initial phase of rest. If the patient fails two cycles of rest and rehab and desires to return to competitive throwing, we would consider UCL reconstruction.

Romeo: The clinical algorithm is clear:

1. Six weeks rest, no throwing, no activities that cause a valgus stress to the elbow, physical modalities, physiotherapy focusing on all aspects of the kinetic chain for overhead activities, and most likely an injection of the athlete’s PRP.

2. If improved with the pain resolved, then a return to throwing program begins. Physiotherapy continues with special attention to core training and other aspects of the kinetic chain away from the elbow.

3. If there is a recurrence of symptoms, then a second round of rest, physiotherapy, and definitely consider an injection of the athlete’s PRP.

4. If all efforts fail, then I recommend UCL reconstruction with a palmaris or gracilis autograft. Rarely, for isolated humeral-sided partial injury, where the rest of the ligament appears relatively normal on MRI, consideration for repair alone without graft reconstruction.

Ahmad: How would you treat a 24-year-old professional pitcher with partial UCL tear?

Ciccotti: My treatment protocol for a professional pitcher with a partial UCL injury is the same as it would be for the high school pitcher with a partial injury. A close, precise examination of the involved elbow as well as ipsilateral shoulder and entire kinetic chain is carried out. Plain X-rays, MRI and SUS have helped determine the degree of laxity in the injured UCL ligament. The same nonoperative program as described for the high school pitcher would be carried out for the elite pitcher.

In professional baseball, however, there is a heightened urgency from the moment of injury to return the athlete to competition. External pressures often focus on surgical treatment. This may be in large part due to “urban” myths or misconceptions that exist with respect to UCL reconstruction. It has been suggested by non-medical professionals that UCL reconstruction will allow a pitcher to throw with higher velocity and more precision. In fact, a recent public perception study carried out by Dr. Ahmad has confirmed this misconception among players, parent and coaches. Although some elite level pitchers may show improvements in performance metrics after return from UCL reconstruction, other studies suggest these improved performance metrics are inconsistent and not sustained.

The apparent postoperative improvement in performance may be due to a combination of prolonged rest, reconstruction of a chronically injured UCL followed then by an intense physical therapy program focused on the entire kinetic chain, overall optimal conditioning of the athlete, and focused attention on throwing mechanics most often under the guidance of a pitching coach. What is equally important to understand is that though UCL reconstruction has a high success rate, upwards of 10% to 20% of pitchers may not return to their previous level of pre-injury performance after this procedure.

ElAttrache: I would try up to 12 weeks of rest and rehab. I would include PRP or a bone marrow aspirate injection to augment healing. If the partial tear occurs in spring training, I would be more aggressive. I would try rest and rehab for 6 weeks, then proceed with reconstruction if still symptomatic so that the player doesn’t lose 2 seasons.

Romeo: The clinical algorithm of treatment is similar to the 16-year-old with a partial UCL tear, but is often adjusted due to issues external to his actual elbow injury.

1. Six weeks rest, no throwing, no activities that cause a valgus stress to the elbow, physical modalities, physiotherapy focusing on all aspects of the kinetic chain for overhead activities, and a strong recommendation for an injection of PRP.

2. If improved and with pain resolved, then a return to throwing program begins. Physiotherapy continues, with special attention to core training and other aspects of the kinetic chain away from the elbow.

3. If there is a recurrence of symptoms, then a second round of rest, physiotherapy, and another injection of the athlete’s PRP. This second round may be lengthened or shortened in time depending on the time of the season and expectations for the athlete.

4. If all efforts fail, then I recommend UCL reconstruction with a palmaris or gracilis autograft.

Ahmad: How successful is Tommy John surgery in professional baseball?

Conte: To answer that question, one must need to define success. This definition may differ from the professional player compared to the high school or collegiate pitcher. Traditionally, outcome studies have used the Modified Conway Score to measure success. This is the pitcher returning to their previous level of competition. In professional baseball, just coming back to reach the previous level may not be good enough for them to maintain their position on the team. They must come back and compete at that level. Any significant drop in their performance metrics will result in demotion or even being released. Therefore, unfortunately, being healthy enough to pitch may not be good enough to have a successful return.

Cain and colleagues published the largest study on outcomes on UCL reconstructions in 2010 with a population of 743 players undergoing the procedure from 1988 to 2006. They showed an 83% return to the previous level of completion. This demonstrated a high probability of success, however, when looking at the professional player, they showed a lesser rate of 75% and 73% rate for major and minor league players, respectively. Although still good results, it is less than the overall group.

More recently, two studies published in 2014 looked exclusively at MLB pitchers. Erikson and colleagues evaluated 179 major league pitchers and found 83% returned to pitch in the MLB. This was an improvement over Cain’s study in the population of major league pitchers. They also found 97% were able to return to the majors or minor leagues. In looking at performance, they found that after surgery the pitchers had significantly improved performance metrics vs. before surgery. They reported a decrease in ERA, fewer walks, hits, runs and home run when they returned.

Ahmad and colleagues studied 147 major league pitchers and found 80% of the pitchers returned to pitch at least one game in the majors. This is similar to the two previous studies. However, only 67% of established pitchers returned to pitch at least 10 games in the major leagues. In addition, 57% of the established pitchers returned to the disabled list because of injuries to the throwing arm. In examining performance metrics, the study showed a decline in some performance metrics but these declines were not statistically different than the age-adjusted matched controls.

UCL reconstruction in the professional players remains to be highly successful demonstrating a consistent 80% or more return rate to the previous level. More studies will continue to focus on not only the return to previous levels but also if the player can maintain or even improve his performance on the field upon return.

Ahmad: What can we expect in the future with regard to UCL injuries?

Andrews: If we can get the message out about national initiatives, such as the STOP program and the Pitch Smart program, then we will be able to educate parents, coaches and young athletes alike. It is important for the future of MLB to prevent injuries at the youth level. Education is the main way to get control. For me, education at a grassroots level is a national initiative. Coaches, particularly youth coaches, need to be educated and involved in some type of state accreditation through courses that emphasize teaching the mechanics of proper throwing and safety standards. Accreditation and education for youth, high school and college coaches is essential. Hopefully with that, we can curtail UCL injuries and allow young throwers to grow up to be true prospects for a long career. Prevention is the key.

Ciccotti: There has been a heightened focus on UCL injury in the throwing athlete perhaps because of the recent apparent epidemic of injury at the most elite level. This heightened focus has resulted in research involving all aspects of this injury. The results of this research will most likely provide better diagnostics, more precise nonoperative rehabilitation programs possibly involving the use of biologics, improved and less invasive surgical techniques, more thorough understanding of the postoperative rehabilitation program, including ideal return to play, tossing and throwing programs and optimal throwing mechanics.

MLB is determined to thoroughly evaluate ulnar collateral ligament injuries. Four years ago, MLB instituted an injury surveillance system to tracks all medical events in all professional baseball players in every organization at all levels. Because of this, more precise epidemiologic data on UCL injures will generate true, focused statistics with respect to injury risks. In addition, MLB studies are being performed to determine the outcomes of UCL surgery from a player’s subjective prospective as well as with the use of an objective scoring system. Biomechanical evaluation of normal uninjured professional pitchers and UCL reconstructed pitchers has been completed to determine if the kinematics and kinetics of throwing are restored in the UCL reconstructed pitcher. Lastly, a prospective evaluation of pitchers, including physical examination, imaging and biomechanical testing is being initiated to identify possible predictive factors for subsequent UCL injury. All of this research is being carried out to identify injury risks and create preventive programs. MLB and the MLB Team Physicians Association continue their tireless pursuit of improved diagnosis, treatment and prevention of UCL in baseball.

Conte: I think there will be two specific areas of increased studies and knowledge in the foreseeable future. The first will the determination of specific risk factors in UCL injuries. This is critical to a long-term prevention program that reduces the number of pitchers who require UCL reconstruction. Without knowing which factors or combination of risk factors increase these injuries, we will continue the increase in players requiring the surgery.

The other area is in determining which players can return successfully to pitching with nonsurgical conservative care. Determining which category of UCL partial tears can return to play without surgery is the first step. The use of orthobiologics where we potential can get actual healing vs. simple scarring of the injured ligament will be critical in conservative care. The amount of rest after injury and a research based return to play program, including a progressive throwing program will need to be established. Little research has been done in this area with the Rettig and colleagues being the most referenced study. This small sample study only shows a 42% success rate. More recently, Podesta and colleagues showed promise with an 88% success rate with the use of rest and PRP injection. This is hopeful but a larger study utilizing professional pitchers and controls needs to be performed.

Donohue: The long-term future of UCL injuries is bright. Much is being done to help young throwers preventively through rules and regulations on limiting the amount of pitching that is allowed. All the research that has been and is being done shows how much the cumulative amount of pitching can cause catastrophic changes to the elbow. It has shown how specialization of sport for young athletes can cause long-term issues, instead a well-rounded background of various sports is beneficial. As far as short term future of UCL injuries, it may not be as hopeful. Increased velocity and UCL injuries seem to go together proportionally and every young pitcher wants to throw harder. Hopefully our young athletes mature through regulated leagues and conditioning and strengthening programs progress as well as our research and pitching mechanics get more advanced, we will see less of this UCL problem we have seen recently.

ElAttrache: I believe we will continue to see UCL tears in teenage patients as more are able to throw with high velocity at a young age. Hopefully, we can control this by limiting exposure. To accomplish this, we must limit the number of months of play to prevent general fatigue and overuse. We must inform coaches and parents regarding the negative effects of over-play, early specialization and fatigue. Biologic enhancement of healing after injury as well as after reconstruction will likely be a helpful adjunct to success in treatment. Properly progressing and timing return to play after reconstruction. To optimize this process, we will need to gain a better understanding and methods to assess graft maturization and healing.

Fleisig: In the 1990s, we saw a growing number of UCL injuries, especially in adolescent baseball pitchers. Biomechanical and epidemiologic research led to recommendations and regulations in youth pitching limits, and the rate of adolescent UCL injuries stopped increasing. I am optimistic that the overall rate of UCL injuries will level off and perhaps decline. This optimism is based upon the recent commitment and educational efforts by MLB, USA Baseball and others toward baseball safety at all levels. I believe amateur players, parents and coaches will wake up to the dangers of excessive pitching and other risk factors. I also believe collegiate and professional baseball teams will begin to be cautious in drafting high-risk pitchers, which will further incentivize adolescent pitchers and their families to minimize UCL injury risk.

Romeo: A great effort has been made to better understand UCL injuries, but we are just beginning to put this all together in way to prevent injuries and improve the rate of return to same level of play after injury. I believe the immediate future has 4 main components:

1. Higher awareness and compliance with prevention programs based on science;

2. Better biologic treatment of partial UCL tears. Platelet rich plasma is a start, but it is likely that a combination of growth factors with regenerative cell therapy from the patient’s own stem cells will play an important role in healing UCL injuries and avoiding surgical reconstruction.

3. Better surgical procedures will allow acceleration of the rehabilitation process, such as repair with synthetic augmentation. This concept has already been shown to be successful in other ligaments, especially around the foot and ankle, and is likely to increase the security of repair and speed the recover process.

4. Better understanding of return to same level of play criteria, avoiding the risk of recurrence which has a much less successful outcome of treatment. This will be facilitated by advancing technology and the ability to identify the onset of fatigue that puts the elbow at risk.

Yenchak: We will demonstrate that our hypotheses are correct starting with the education of youth. It starts there. Behaviors that are instilled within the youth will carry significant weight as they work their way up the competitive ladder of baseball. Early onset injury prevention strategies will drive the evolution of periodization models, combat controversy regarding long toss programs, fine-tune rehabilitation/strength protocols that take a less-is-better approach, and help us better understand the role of alternative medicine in the algorithm of patient care.

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.