Opening day is upon us, as spring and baseball return to Philadelphia. Whether the Taney Dragons or the Phillies or neither win the World Series this year, one thing is certain – there will be players who suffer from injuries to the elbow. Such injuries are particularly common in pitchers. In fact, the elbow joint comprises 26% of all injuries sustained by Major League Baseball pitchers1. The overhead throwing mechanics result in microtrauma and stress to the inside (medial) part of the elbow. The ulnar collateral ligament (UCL)holds the elbow together in the throwing phase. Changes to theshoulder mechanics or changes in pitching mechanics result in increased stress loads to the UCL.
The good news is that we can prevent most UCL injuries. The total range of motion (TROM) of the shoulder is measured by how far the shoulder joint goes from external range of motion to internal range of motion. The pitching arm will often go further back in external rotation and less in internal rotation. Decreased TROM of the throwing shoulder joint arm is a major risk factor for injury ofoverhead athletes. A five degree deficit in TROM is associated with increased risk of UCL tear in baseball players. Decrease in internal rotation (glenohumeral internal rotation deficit (GIRD)) is prevalent in throwers, but may not be associated with increased injury risk of UCL injury2. Other risk factors associated with pitching injuries include weak hip strength on the plant leg, poor pitching mechanics, and excessive pitching counts3. Any repetitive overhead activity puts athletes at risk. Little League has implemented pitch limits to decrease injuries, but due to travel leagues, athletes are commonly playing year-round causing injuries.
Prevention of UCL injuries should focus on maintaining shoulder range of motion and core strengthening. A structured stretching and strength training routine which includes improving core strength is likely to prevent injuries. The shoulder TROM can be corrected by doing the sleeper stretch daily. Working on the shoulder strength should be done by doing the thrower ten exercises. Hip strength can be accomplished by doing the five hip exercises for better hip strength.
For throwing athletes, if the elbow hurts on the inside, you should be seen by a sports medicine physician. It is important to prevent partial UCL injuries from developing into full or high partial tears. The doctor will ask important questionsand examine both elbows, shoulders and hips. Further tests will often be ordered. Musculoskeletal ultrasound can identify early injuries and can be done in the office.Ultrasound may help differentiate injury to the ligament, flexor muscle or the growth plate (apophysis) as the cause off elbow discomfort. MRI is often used for evaluation of elbow injuries. Stress radiography can be helpful for evaluation of the UCL.Valgus stress opening seen on stress radiographs increases dramatically from a partial tear (0.1 mm) to full tear (0.6 mm) 5.
For partial thickness tears, treatment include stopping pitching, rehabilitation exercise to strengthen and provide support to the damaged ligament, and correction of shoulder, core and hip abnormalities. Platelet-rich plasma injections may be an additional treatment option for partial tears. A recent study showed success with return to play in 88% of athletes with average return at 12 weeks post procedure6. Athletes with a high-grade partial or complete tear of the anterior band of the UCL on MRI will often need surgery to reconstruct the UCL due to lack of success of non-operative treatment7.With UCL reconstruction, (commonly called Tommy-John Surgery), holes are drilled in the humerus and ulna, then the UCL is replaced with a tendon from elsewhere in the body; the damaged ligament may be sown into the tendon to increase strength. When considering return to competition, an average length of recovery is estimated to be approximately 12-16 months8. After 6 months, light overhead activity may be resumed and at 9 months more competitive throwing may resume. Recovery rates have typically been reported as the ability for an athlete to return to his or her pre-injury level of competition and these recovery rates have been reported to be approximately 70% to 80%8.
Throwing athletes need to understand the risks of repetitive overhead activity, the benefit of improved technique and the use preventative exercises to avoid potential injury. Education, stretching and strengthening is paramount to decreasing the need for time on the bench. It is important to be seen by a doctor when the elbow starts to hurt so a minor injury does not sideline you or your thrower for a long time.
1: Posner M, Cameron KL, Wolf JM, Belmont PJ Jr, Owens BD. Epidemiology of Major League Basebal Injuries. Am J Sports Med. 2011:39(8):1676-1680
2: Garrison JC, Cole M, Conway J, Macko M, Thigpen C, Shanley E. Shoulder Range of Motion Deficits in Baseball Players with Ulnar Collateral Ligament Tear. Am J Sports Med. Nov 2012:40(11):2597-2603
3: Shanley E, Thigpen C. Throwing Injuries in the Adolescent Athlete. Int J Spots PhysTher: 2013 Oct: 8(5): 630-640
4: Shanley E, Michener LA, Ellenbecker TS, Rauh MJ. Incidence of Shoulder and Elbow Injuries in High School Softball and Baseball Players. Journal Athletic Training. 2011;45(4).
5: Bruce JR, Hess R, Joyner P, Andrews JR. How Much Valgus Instability can be Expected with Ulnar Collateral Ligament (UCL) Injuries? A Review of 273 Baseball Players with UCL Injuries. J Shoulder Elbow Surgery, 2014: Oct: 23(10): 1521-1526.
6: Podesta L, Crow S, Volkmer D, Bert T, Yocum L. Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow with Platelet Rich Plasma. Am J Sports Med. July 2013: 41(7): 1689-1694
7: Kim NR, Moon, SG, Ko SM, Moon WJ, Choi JW, Park JY. MR Imaging of Ulnar Collateral Ligament Injury in Baseball Players: Value for Predicting Rehabilitation Outcome. European Journal of Radiology, Vol 80, Iss 3, Dec 2011, e422-e426
8: Makhni E, Lee R, Morrow Z, Gualtieri A, Gorrochurn P, Ahmad C. Performance, Return to Competition, and ReinjuryAfter Tommy John Surgery in Major League Baseball Pitchers: A Review of 147 Cases. Am J Sports Med. June 2014: 42(6): 1323-1332
This post was written with contribution from Dr. Timothy J. Gill.
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