AAOS ICL focuses on baseball pitchers with elbow issues and how to evaluate, repair, and reconstruct UCL tears

For orthopaedic surgeons, spring brings a wave of baseball pitchers presenting with elbow issues. Their complaints may include decreased velocity and control, numbness, tingling, stiffness, and ulnar-sided pain. During Instructional Course Lecture 129, “Elbow ulnar collateral ligament (UCL) tears: Evaluation and treatment,” a panel of experts weighed in on how to approach these injuries.

Eric Bowman, MD, MPH, FAAOS, associate professor at Vanderbilt University Medical Center, presented first. He recommended thoroughly going over the player’s history and routines, asking such questions as: Have they changed their technique or training regimen? What types of pitches do they throw and how fast? How many months do they play? Are they involved in other sports or do they play other positions? Do they use weighted balls?

“Probably most importantly, what are their goals?” Dr. Bowman suggested. “Do they want to play at the next level, or is this just a ‘get me through the year’ situation? How many months of the year are they resting, and how many days per week? When it comes to pitch types, even if you don’t know a lot about baseball, just probing this can give you a little bit more understanding.”

During a patient’s exam, Dr. Bowman starts with everything outside the UCL: shoulder range of motion, scapular control, core strength. He also has patients do single-leg squats to test balance — poor balance can increase the risk of injury.

“The elbow is just the end of the line,” he said. “If they have decreases in strength, balance, etc., they’re going to lose that efficiency, and then they’re going to try to make that up with their arms. Most of these kids, they’re just used to throwing hard. They haven’t had to develop the lower extremity. Just doing these simple tests in the clinic shows the patient and the family that, yes, there are definitely some issues here that need to be worked through.”

Other signs of UCL insufficiency are posterior medial pain, flexor pronator pain or strain, and lateral compression. These issues, especially in combination, show that the UCL is not functioning the way it should. For imaging, Dr. Bowman and other panelists recommended getting a flexed elbow valgus external rotation (FEVER) view, to better visualize the UCL under stress.

UCL repair
Michael Freehill, MD, chief of the shoulder and elbow service at Stanford University School of Medicine, noted that many UCL injuries are in patients aged 15 to 19 years old. Part of the problem is specialization, with kids playing only one sport or even just one position (pitcher).

To support assessment, Dr. Freehill recommends the “5 Ps.” Developed by Keith Meister, MD, team physician for the Texas Rangers, these questions can help determine the best way to approach the injury:

• Play level: Do they play at the high school, college, minor league, or major league level? Do they plan to evolve in level?
• Position: Are they a pitcher or position player?
• Personality of the tear: Is the tear proximal, distal, or midsubstance? Does it have soft-tissue or bony considerations?
• Period: Where are they in the season?
• Potential: What is a realistic upside for the athlete?

Through this assessment process, surgeons can better determine the appropriate treatment: rest, repair, or reconstruction. “With repair, you could get people back to their throwing program by 10 weeks, potentially competing again in four months,” Dr. Freehill said. “When you do a reconstruction, they might not even start their throwing program until four months [postoperatively] — probably some of us move that back a bit more now. They might not be competitive until a year [later], and probably longer in the pros.”

UCL reconstruction
Matthew Smith, MD, FAAOS, professor of sports medicine in the Washington University Department of Orthopaedics, asked the simple question: “How do we do better? How do we improve these reconstructions?”

One way is using suture augmentation to reinforce the ligament, potentially improving stability and speeding up recovery. In a study by Bernholt et al., 12 UCLs were reconstructed without suture augmentation, while 12 received heavy braided tape tied over a 2 mm wedge. The researchers found that UCL reconstruction using internal brace augmentation demonstrated improvements in stiffness and time-zero failure strength versus a standard docking technique.

Another study, by Romeo et al., investigated double docking with augmentation. Suture augmentation improved cyclic stiffness and lowered gap formation compared with standard docking. Still, the evidence is uneven, and much more work needs to be done to figure out the best ways to help these athletes.

“UCL reconstruction does very well for returning athletes back to their previous level of play,” Dr. Smith said. “Graft choice and surgical technique really don’t matter based on current literature. Although UCL reconstruction does improve biomechanical performance, we don’t have good data that show its clinical superiority. We may be able to get them back sooner, but what are the consequences in the graft and the bone when we’re putting all these augmentations in?”

Cases
Peter Chalmers, MD, FAAOS, associate professor of shoulder and elbow surgery at the University of Utah, weighed in by describing cases studies and opening them up to the panel for consensus rulings.

In the first case, a 16-year-old high school pitcher with the potential to play in college had a midsubstance injury and could no longer pitch. The panel felt the injury was too severe for conservative treatment and would require reconstruction.

The second case was a high school gymnast with a commitment to a Division I school. The panel discussed the choice between repair and reconstruction. The gymnast had good tissue, so ultimately, treatment involved a repair, internal brace, and slow rehabilitation.

For this case, the primary question Dr. Chalmers posed was, “What are you willing to risk?” He added, “A distal tear and a high-level gymnast: I’ve seen them heal, but I’ve also seen them not heal. You have to make sure you know what their timing is so that you can match that up. I think I’d be a little bit more aggressive in this potential situation.”

Josh Baxt is a freelance writer for AAOS Now.

References 

1. Dugas JR, Walters BL, Beason DP, et al. Biomechanical comparison of ulnar collateral ligament repair with internal bracing versus modified Jobe reconstruction. Am J Sports Med. 2016;44(3):735-741. doi:10.1177/0363546515620390
2. Roth TS, Beason DP, Clay TB, et al. The effect of ulnar collateral ligament repair with internal brace augmentation on articular contact mechanics: A cadaveric study. Orthop J Sports Med. 2021;9(4):23259671211001069. doi:10.1177/23259671211001069
3. Bernholt DL, Lake SP, Castile RM, et al. Biomechanical comparison of docking ulnar collateral ligament reconstruction with and without an internal brace. J Shoulder Elbow Surg. 2019;28(11):2247-2252. doi:10.1016/j.jse.2019.04.061
4. Romeo AA, Erickson BJ, McClish SJ, et al. Biomechanical comparison of novel ulnar collateral ligament reconstruction with internal brace augmentation vs. modified docking technique. J Shoulder Elbow Surg. 2022;31(10):2001-2010. doi:10.1016/j.jse.2022.03.020