Elbow Ulnar Collateral Ligament Injuries Research Articles

Psychological Impact and Posttraumatic Stress Disorder Symptomatology After Ulnar Collateral Ligament Injuries in Baseball Players.

Significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been well documented in patients sustaining anterior cruciate ligament injury. To examine PTSD symptomatology in baseball players after sustaining elbow ulnar collateral ligament (UCL) injury. Cross-sectional study; Level of evidence, 3. Male baseball players of various competition levels (high school through Minor League Baseball [MiLB]) who underwent surgery for a UCL injury between April 2019 and June 2022 participated in the study. Before surgery, patients completed the Impact of Event Scale-Revised (IES-R) to assess PTSD symptomatology. Subgroup analysis was conducted according to level of play and player position. A total of 104 male baseball players with a mean age of 19.4 years (range, 15-29 years) were included in the study; 32 players (30.8%) were in high school, 65 (62.5%) were in college, and 7 (6.7%) were in MiLB. There were 64 (61.5%) pitchers, 18 (17.3%) position players, and 22 (21.2%) 2-way players (both pitching and playing on the field). A total of 30 (28.8%) patients scored high enough on the IES-R to support PTSD as a probable diagnosis, and another 22 patients (21.2%) scored high enough to support PTSD as a clinical concern. Nineteen patients (18.3%) had potentially severe PTSD. Only 4 players (3.8%) were completely asymptomatic. Subgroup analysis revealed college players as significantly more symptomatic than high school players (P = .02), and 2-way players were found to be significantly less susceptible to developing symptoms of PTSD compared with pitchers (P = .04). Nearly 30% of baseball players who sustained a UCL injury qualified for a probable diagnosis of PTSD based on the IES-R. Pitchers and college athletes were at increased risk for PTSD after UCL injury compared with 2-way players and high school athletes, respectively.

Editorial Commentary: Sex-Specific Differences in Elbow Ulnar Collateral Ligament Injuries: A Retrospective Analysis

Orthopedic injuries in female athletes continue to rise at a dramatic rate at every level of competition. This has sparked increased research interests into the pathoanatomy, epidemiology, treatment, and outcomes related to sex-specific differences involving ligament injuries, including ulnar collateral ligament (UCL) injuries. However, most published research studies have been limited when evaluating for any sex-specific differences beyond anterior cruciate ligament (ACL) injuries. Most UCL-related research, especially as it pertains to high level athletes, has occurred in the realm of professional baseball, a male-dominated sport. While there are small reports of UCL injuries in females, these injuries are more common in women who participate in track and field (javelin), and gymnastics. It is imperative for our orthopedic surgery community to continue to advance our understanding of sex-related differences in elbow UCL injuries to improve our injury understanding and ultimately help improve treatment and rehabilitation protocols for both male and female athletes with regards to different ligament injuries.

The Use of MSK Ultrasound in the Evaluation of Elbow Ulnar Collateral Ligament Injuries.

As physical therapists, understanding the anatomy and biomechanics of the musculoskeletal system is essential for accurate diagnosis and effective treatment outcomes. Musculoskeletal ultrasound (MSK-US) is one tool that has revolutionized the way physical therapists evaluate musculoskeletal pathology. Specific to the elbow, assessing the ulnar collateral ligament (UCL) proves especially beneficial for providing both diagnosis and treatment planning. By directly visualizing static and dynamic loads to the ligament, physical therapists can gain valuable information about underlying pathology and guide the therapeutic decision-making process. In this sound byte, we will look at how incorporating MSK-US imaging into your patient assessments can provide you with more comprehensive data to make informed clinical decisions when treating UCL injuries in the elbow.

Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis

Background: Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear. Purpose: To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries. Results: A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757). Conclusion: For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.

Hypertrophy of the sublime tubercle in elbow ulnar collateral ligament injuries: a case series of baseball pitchers undergoing ulnar collateral ligament reconstruction with short-term follow-up

The ulnar collateral ligament (UCL) of the elbow is subject to repetitive stress in overhead throwing athletes. This can lead to morphologic changes at the bony attachments of the UCL and hypertrophy of the sublime tubercle. The purpose of this case series is to describe the surgical details and clinical outcomes of a series of competitive baseball pitchers with hypertrophic sublime tubercles who underwent UCL reconstruction (UCLR). All baseball pitchers who were treated for UCL injuries with significant hypertrophy of the sublime tubercle on preoperative imaging were included in the series. Clinical history, preoperative imaging, intraoperative findings during UCLR, and postoperative outcomes measured with the Conway scale were described. Ten players (average age of 22.9 years [range 13-39]) were included (average follow-up 20.4 months [range 3-38 months]). Five patients also had symptoms of ulnar nerve compression, with 4 requiring transposition at the time of ULCR and 1 at 3 months postoperatively. Bony hypertrophy of the sublime tubercle was confirmed intraoperatively in all cases and excised before UCLR with the docking technique. Of the 7 patients with at least 12-month follow-up postoperatively, 6 had excellent outcomes, and 1 had a fair outcome. Although UCLR in the setting of hypertrophic sublime tubercle can be more complex than typical UCLR, excellent outcomes are achievable with preoperative recognition and surgical planning.

YouTube as a source of patient education information for elbow ulnar collateral ligament injuries: a quality control content analysis.

BackgroundWhile online orthopedic resources are becoming an increasingly popular avenue for patient education, videos on YouTube are not subject to peer review. The purpose of this cross-sectional study was to evaluate the quality of YouTube videos for patient education in ulnar collateral ligament (UCL) injuries of the elbow.MethodsA search of keywords for UCL injury was conducted through the YouTube search engine. Each video was categorized by source and content. Video quality, reliability, and accuracy were assessed by two independent raters using five metrics: (1) Journal of American Medical Association (JAMA) benchmark criteria (range 0–4) for video reliability; (2) modified DISCERN score (range 1–5) for video reliability; (3) Global Quality Score (GQS; range 1–5) for video quality; (4) ulnar collateral ligament-specific score (UCL-SS; range 0–16), a novel score for comprehensiveness of health information presented; and (5) accuracy score (AS; range 1-3) for accuracy.ResultsVideo content was comprised predominantly of disease-specific information (52%) and surgical technique (33%). The most common video sources were physician (42%) and commercial (23%). The mean JAMA score, modified DISCERN score, GQS, UCL-SS, and AS were 1.8, 2.4, 1.9, 5.3, and 2.7 respectively.ConclusionsOverall, YouTube is not a reliable or high-quality source for patients seeking information regarding UCL injuries, especially with videos uploaded by non-physician sources. The multiplicity of low quality, low reliability, and irrelevant videos can create a cumbersome and even inaccurate learning experience for patients.

Elbow Ulnar Collateral Ligament Injuries in Overhead Athletes: An Infographic Summary.

Ulnar collateral ligament (UCL) injuries of the elbow are common in throwing athletes. Given that the UCL's primary function is to provide valgus stability during the deceleration phase of throwing, injury to the UCL will render throwing difficult to nearly impossible.15 Injuries will occur more so in the sports of baseball, softball, and javlineers participating in track and field.5,10,14 Data has indicated that valgus torque reaches 64 N-m and proximal forces as high as 1000 N to prevent elbow distraction. Further, angular velocity across elbow may reach 1900-2480 degrees/second.6,8 Imaging modalities that have the greatest accuracy for diagnosis include magnetic resonance imaging (MRI), MRI-arthrogram, and stress ultrasonography.2,3,11,12 Treatment of UCL injury depends on multiple factors. These include if the injury is a partial tear or complete tear and the location (distal versus proximal) of the partial tear.7 Further, complete tears, as well as partial distal tears, are more likely to undergo surgical intervention.1,13 Treatment decision-making is primarily dependent on following factors: location, severity, if the patient is a throwing athlete, and if the patient is in his or her last year of his/her throwing career due to the length of the rehabilitation process if surgery is pursued.15 Return-to-play success rates when treated conservatively vary from anywhere from 42% to 100%. Conservative treatment includes rest, rehabilitation, platelet-rich plasma injections, and a throwing program.4 Surgical treatment has evolved significantly with various reconstructive techniques and (when indicated) surgical repair with internal bracing. Return-to-play rates are high, ranging from 80% to 95% with low complication rates, but rehabilitation for reconstruction can range from 12-18 months or longer. Therefore, patients must be made aware of the commitment to the rehabilitation process if electing to undergo surgical reconstruction.9.

Repair of the ulnar collateral ligament: a review of current trends and outcomes

Diagnosis and surgical treatment of elbow ulnar collateral ligament (UCL) injury is becoming more common. A thorough understanding of nonsurgical and surgical options for this injury is required for successful treatment. Gold standard treatment remains ligamentous reconstruction with autograft in the elite throwing athlete. However, advances in surgical technique, technology, and a better understanding of the pathoanatomy of the injury has renewed interest in primary repair of the UCL. Recent literature has shown encouraging results with primary repair and with augmented primary repair, especially over the past 5 yr. This review describes the recent trends and outcomes of UCL repair so that surgeons can have a better understanding of surgical options.

Seasonal and monthly trends in elbow ulnar collateral ligament injuries and surgeries: a national epidemiological study

Monthly incidence of elbow ulnar collateral ligament (UCL) injuries and surgeries is relatively unknown. Defining seasonal peaks of UCL injuries and surgeries may identify opportunities for injury-prevention strategies. The purpose of this study is to analyze seasonal and monthly variations in UCL injuries and surgeries across the United States with emphasis on the timing of baseball season. The Truven Health MarketScan database (2013-2015) was queried for patients younger than 40 years with a diagnosis code of elbow UCL sprain and a procedural code for UCL repair or reconstruction. Differences in patient characteristics were evaluated using chi-square and Mann-Whitney U-tests. Negative binomial regression models were calculated for UCL injuries and surgeries to assess monthly trends. UCL injuries were sustained by 13,894 patients, with 1404 (10.1%) patients having undergone surgery. The median age at first diagnosis was 17 years, and the median age of patients requiring surgery decreased from 20 to 18 years from 2013 to 2015 (P= .75). Most UCL injuries (n= 3785) and surgeries (n= 438) occurred during the spring season (March 21-June 20), and spring injuries were most likely to result in surgical management (11.6%). During the baseball season (March to September), the number of UCL injuries peaked in April/May, then declined, except for a second peak in September/October (incidence rate ratio 0.97; confidence interval 0.95, 0.99; P= .01). The number of UCL surgeries steadily increased from March (n= 116) to June (n= 152), followed by a gradual decline (incidence rate ratio 1.00; confidence interval 0.96, 1.04; P= .99). Athletes frequently experienced UCL injuries and surgeries in the early months (April-June) of the baseball season. More emphasis should be paid to rehabilitative strategies at the beginning of a baseball season to help mitigate injury risk.

Adolescent Pitcher Fatigue: Ulnar Collateral Ligament Stress, Flexor-Pronator Mass Energy Depletion, and Correlation to Pitch Count

Objectives:There has been a rise in elbow ulnar collateral ligament (UCL) injuries in youth pitchers over recent years. With forearm flexor-pronator mass fatigue, the dynamic stability provided could be diminished placing greater stress on the UCL. Pitch count limits have been instituted in an attempt to help curtail this rise in throwing injuries, especially in youth athletes. In order to provide more objective data regarding current pitch count limits for youth pitchers, the purpose of this pilot study was to evaluate for potential fatigue of the flexor-pronator mass by assessing changes in medial elbow laxity, noninvasively characterizing changes in muscle glycogen storage within the forearm flexor-pronator mass, and evaluating changes in subjective fatigue, strength, range of motion (ROM), pitching velocity, and accuracy with increasing number of pitches thrown by 10-year-old pitchers up to their recommended 75 pitch count limit.Methods:After appropriate power analysis, male pitchers 10 years of age were recruited for the study (n=22). Pitchers threw a total of 75 pitches divided into sets of 25 pitches, with standardized periods of rest in between throws and sets to best simulate a game. Bilateral medial elbow laxity was measured by applying 10 decanewtons of valgus force with a standardized stress device and utilizing ultrasound imaging (Figures 1A-B) prior to pitching and after each pitching set. The change in medial ulnohumeral joint distance (Figure 1C) after stress was applied was calculated from baseline without stress. Relative changes in muscle glycogen storage, detected as changes in echogenicity, within the flexor carpi radialis (FCR) and the flexor digitorum superficialis (FDS)/flexor carpi ulnaris (FCU) muscles were measured non-invasively with ultrasound-based software (Figures 1D-E) and recorded as fuel percentile. Repeated measures analysis of variance and post-hoc testing were used to determine statistical significance (alpha=0.05).Results:There were no significant differences in medial elbow laxity between arms or time points. There was a trend for similar decline in FCR fuel percentile values between each arm, indicating relative decreases in glycogen storage bilaterally. However, only the throwing arm demonstrated a statistically significant decline in fuel percentile from baseline to after 75 pitches (p=0.05). There were no statistically significant differences across time points for FDS/FCU fuel percentile values. Fatigue measurements for both arms were significantly higher at all time points compared to baseline (p≤0.03). Grip strength of the dominant arm after 75 pitches was significantly decreased compared to after 25 pitches (p=0.02). There were no statistically significant changes in other strength measurements, ROM, velocity, or accuracy between all time points.Conclusions:By the recommended 75 pitch count limit in 10-year-olds, subjective fatigue and a decrease in grip strength had occurred. Furthermore, relative glycogen storage of the flexor-pronator mass of the throwing arm decreased between pitching 50 to 75 pitches, but without an increase in medial elbow gapping. This study provides a foundation and raises questions for further objective testing of physiologic changes that occur throughout increasing pitching to better guide pitch count limits and ensure the safety of young athletes

Forearm flexor injury is associated with medial ulnar collateral ligament injury in throwing athletes.

Elbow ulnar collateral ligament (UCL) injuries have become increasingly common in throwing athletes. The forearm flexors (FF) have been studied as biomechanical stabilizers for the medial elbow. However, there are no studies investigating the association of concomitant UCL injuries and FF injuries in throwing athletes. To determine if throwing athletes with a complete UCL injury had a greater likelihood of concomitant FF injury than those with a partial UCL injury. Descriptive retrospective epidemiological study. Academic, tertiary care medical center. Throwing related UCL injuries in patients aged 12-24 years. Electronic medical records and key word searches identified all patients from January 1, 2010 to December 31, 2019. A board certified and fellowship trained musculoskeletal radiologist reviewed all advanced imaging studies. Fifty-four patients (46 male, 8 female, mean age 17.1 years, SD 2.3) were included. Fifty-four UCL injuries (21 complete ruptures, 16 proximal partial injuries, 17 distal partial injuries) were confirmed by magnetic resonance imaging (MRI). Twenty-eight FF injuries (22 strains, 6 tears) were diagnosed with MRI and/or MRI-arthrogram. There was a significant association between sustaining a FF injury and UCL reconstruction (UCL-R) (X2 = [1, N= 54], = 3.97, P= .046) (15/22, 68.2%), as well as FF injury and UCL injury location (X2 = [1, N= 33], = 3.86, P= .049) (10/17, distal partial UCL injury, 58.8%). Analysis of FF injury and complete UCL tear is not significant (X2 = [1, N= 54], = 3.02, P= .08) (14/21, 66.7%). The data indicate that FF injury is associated with UCL injury in throwing athletes. Future prospective studies should investigate causation versus correlation of FF and UCL injury in throwing athletes. The results of this study have applications to multiple sports medicine areas that include but are not limited to surgical, nonsurgical, prehabilitation, rehabilitation, and sports performance. This study reveals a strongly significant association between FF injury and concomitant UCL injury in throwing athletes.

Return to Play After Platelet-Rich Plasma Injection for Elbow UCL Injury: Outcomes Based on Injury Severity.

Background:Ulnar collateral ligament (UCL) injuries of the elbow are uncommon in the general population but prevalent in the athletic community, particularly among baseball players. Platelet-rich plasma (PRP) injection therapy has become a popular nonoperative adjuvant treatment for such injuries to help reduce recovery time and avoid surgery.Purpose/Hypothesis:To analyze patient outcomes by injury severity and identify injury types that responded most favorably and unfavorably to PRP treatment. It was hypothesized that PRP therapy would prove to be most beneficial in the treatment of lower-grade, partial UCL tears and less effective in the treatment of more severe, complete UCL tears.Study Design:Cohort study; Level of evidence, 3.Methods:A cohort of 50 patients with UCL injuries in their dominant elbow, diagnosed by MRI (magnetic resonance imaging) arthrogram, underwent PRP therapy in conjunction with an established rehabilitation program. UCL injuries were classified by MRI as low-grade partial tear (Type I), high-grade partial tear (Type II), complete tear (Type III), or tear in more than 1 location (Type IV).Results:In total, 24 of 39 (61.5%) Type I and II tears, 3 of 3 (100%) Type III tears, and 1 of 8 (12.5%) patients with Type IV tears responded to UCL PRP injection therapy and were able to return to play without surgery. Ten patients required subsequent UCL PRP injections, of which 3 (30%) were able to return to sport without surgery.Conclusion:PRP treatment for Types I and II UCL tears shows great promise when combined with physical therapy and a rehabilitation program. Type III UCL tears demonstrated a high rate of success, although with low cohort numbers. Type IV UCL tears did not appear to respond well to PRP injection therapy and often required surgical intervention or cessation of sport. Therefore, PRP treatment does not appear to be appropriate for patients with complete Type IV UCL tears but may enhance recovery and improve outcomes in throwing athletes with Types I, II, and III UCL injuries.

The Role of Biologic Agents in the Non-operative Management of Elbow Ulnar Collateral Ligament Injuries.

Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells. Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.

Elbow Ulnar Collateral Ligament Injuries: Indications, Management, and Outcomes

Ulnar collateral ligament (UCL) injuries continue to be a major source of morbidity in baseball players. The throwing motion creates nearly supraphysiological levels of valgus stress on the medial elbow, placing these athletes at high risk of UCL injury. The incidence of injury continues to rise at an alarming rate, especially among adolescent baseball pitchers. Certain risk factors for UCL injury have been identified, including pitch velocity, fewer days between outings, and overall workload. Treatment of UCL injuries depends on the type of tear. Low- to medium-grade partial UCL tears (i.e., grade I or II tears) are usually amenable to a period of rest and a graduated throwing program. Recently, platelet-rich plasma has been described as another treatment modality to consider in a throwing athlete with a partial UCL tear, although robust clinical data are currently lacking. Most athletes can return to competitive throwing in 3 to 4 months after nonoperative management of a low-grade partial UCL tear. Indications for surgical management of a UCL injury are a complete (type III) tear or failure of extensive conservative management after a partial UCL tear. UCL reconstruction remains the gold standard for operative management of a complete UCL tear. Both the modified Jobe technique and the docking technique have shown excellent results with return-to-play rates between 80% and 90%. Recently, UCL repair with collagen-dipped suture tape augmentation has gained some popularity. However, long-term results are lacking, especially in elite athletes. Time to return to play after UCL reconstruction is variable. Most athletes return to full competition in 12 to 15 months, although professional pitchers often require 15 to 18 months to return to their previous level of competition. Revision rates remain low (1%-7%), yet the revision rate is expected to rise as the number of UCL reconstructions performed in the United States continues to increase.

Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis

Background: Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries. Hypothesis: Players who received PRP injections would have better outcomes than those who did not receive PRP. Study Design: Cohort study; Level of evidence, 3. Methods: The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation. Results: Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing (P < .001) and RTP (P = .012). The matched cohort analysis showed that MLB and MiLB pitchers in the no-PRP group had a significantly faster return to throwing (P < .05) and the MiLB pitchers in the no-PRP group had a significantly faster RTP (P = .045). The survival analysis did not reveal significant differences between groups over time. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. Conclusion: In this retrospective matched comparison of MLB and MiLB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.

Epidemiology of Surgical Treatment of Adolescent Sports Injuries in the United States: Analysis of the MarketScan Commercial Claims and Encounters Database

PurposeTo determine whether there is increasing surgical management of adolescent sports injuries and whether the average age of surgical patients is decreasing.MethodsThe Truven Health MarketScan Database was searched from 2008 to 2014 for patients 10 to 19 years of age using the International Classification of Disease, 9th Revision codes and Current Procedure Terminology, 4th Edition, codes for operative treatment for the following conditions: anterior cruciate ligament (ACL) injuries, knee collateral ligament (KCL) injuries, meniscal injuries, Osgood–Schlatter syndrome, and elbow ulnar collateral ligament injuries. Patients identified were characterized by sex, age, year of injury, and type of residence (urban vs rural) based on metropolitan statistical areas.ResultsA total of 516,892 patients sustained 1 of the identified injuries, and 133,541 (25.8%) patients underwent a related surgery. KCL and meniscal injuries demonstrated a consistent increase in the rate of surgical intervention (P < .0001). Average age of surgical intervention did not increase or decrease overall for any diagnosis. Female adolescents were more likely to undergo surgery for KCL injuries (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.58-1.79, P < .0001), Osgood–Schlatter syndrome (aOR 1.8, 95% CI 1.38-2.39, P < .0001), and ACL injuries (aOR 1.5, 95% CI 1.45-1.52, P < .0001), whereas male adolescents were more likely to undergo surgery for meniscal injuries (aOR 1.3, 95% CI 1.24-1.30, P < .0001) and ulnar collateral ligament injuries (aOR 1.1, 95% CI 1.06-1.23, P < .0005). Patients in rural areas were more likely to undergo surgical intervention for ACL and meniscal injuries (P < .0001) and KCL injuries (P = .02).ConclusionsWe found that surgical treatment of 5 common sports injuries remains stable, with only KCL injuries and meniscal injuries showing an increase in surgical incidence. Average age of surgical intervention did not change significantly over the 7-year time span for any diagnosis.Level of EvidenceLevel IV, Cross Sectional Study.

Elbow Injuries in National Collegiate Athletic Association Athletes: A 5-Season Epidemiological Study.

Background:Little research has focused on the rates and patterns of elbow injuries in National Collegiate Athletic Association (NCAA) student-athletes.Purpose:To describe the epidemiological patterns of elbow injuries in NCAA athletes during 5 seasons over the academic years 2009 through 2014 using the NCAA Injury Surveillance Program (NCAA-ISP) database.Study Design:Descriptive epidemiology study.Methods:A voluntary convenience sample of NCAA varsity teams from 11 sports was examined to determine the rates and patterns of elbow injuries. Rates and distributions of elbow injuries were identified within the context of sport, event type, time in season, mechanism, time lost from sport, surgical treatment, and injury type. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). An AE was defined as any student participation in 1 NCAA-sanctioned practice or competition with an inherent risk of exposure to potential injury. Injury rate ratios (IRRs) and injury proportion ratios (IPRs) were then calculated to compare the rates within and between sports by event type, season, sex, mechanism, surgical treatment, and time lost from sport. Comparisons between sexes were made using only sports data that had both male and female samples.Results:Overall, 373 elbow injuries were reported in the NCAA-ISP data set during the 2009-2010 through 2013-2014 academic years among 11 varsity sports. The overall rate of injury was 1.76 per 10,000 AEs. The rate of elbow injuries in men was 0.74 per 10,000 AEs, while women experienced injuries at a rate of 0.63 per 10,000 AEs. In sex-comparable sports, men were 1.17 times more likely to experience an elbow injury compared with women. Men’s wrestling (6.00/10,000 AEs) and women’s tennis (1.86/10,000 AEs) were the sports with the highest rates of elbow injuries by sex, respectively. The top 3 highest injury rates overall occurred in men’s wrestling, baseball, and tennis. Elbow injuries were 3.5 times more likely to occur during competition compared with practice. Athletes were 0.76 times less likely to sustain an elbow injury during the preseason compared with in-season. Contact events were the most common mechanism of injury (67%). For sex-comparable sports, men were 2.41 times more likely than women to have contact as their injury mechanism (95% CI, 0.78-7.38). The majority of athletes missed less than 24 hours of participation time (67%), and only a minority (3%) of patients with elbow injuries went on to have surgical intervention. Elbow ulnar collateral ligament injuries were most common (26% of total injuries).Conclusion:Analysis of the study data demonstrated a significant rate of elbow injuries, 1.76 injuries per 10,000 AEs in NCAA collegiate athletes. Higher injury rates can be expected in males within sex-comparable sports. Elbow injuries are most common in the setting of competitions and most commonly occur secondary to contact-type mechanisms. Injuries were more likely to occur during in-season play. The majority of injuries required less than 24 hours of time away from sport and did not require surgical intervention.

Outcomes of Non-Operatively Treated Elbow Ulnar Collateral Ligament Injuries in Professional Baseball Players by Magnetic Resonance Imaging Tear Grade and Location

Objectives: Evaluate the relationship of 1) MRI tear grade and 2) injury location with outcomes for non-operatively treated elbow ulnar collateral ligament (UCL) injuries in professional baseball players. Methods: 544 professional baseball players were identified from the MLB Health and Injury Tracking System (HITS) that were treated non-operatively for their UCL injuries from 2011-2015. Of these players, 237 MRI’s were directly available for review by an independent, expert musculoskeletal radiologist who evaluated the grade (Grade I -edema, II-partial tear, III-complete tear) and location of the tears (humeral, ulnar, both-sided). Player demographics and outcomes including return to throwing (RTT), return to play (RTP), failed non-operative treatment leading to UCL reconstruction (UCLR), and Kaplan-Meier survivorship analysis of the native UCL to re-injury or surgery based on MRI grade and tear location was measured. A multivariate analysis adjusting for age, MRI grade, tear location, and level of play (Major = MLB; Minor = MiLB) was also performed. Results: The average age of all players was 22.5 years, 90% played at the MiLB level, and 84% were pitchers. The radiologist’s MRI injury grade was distributed as follows: Grade I (36%), Grade II (49%), and Grade III (15%) injuries. The tear locations were distributed as follows: humeral (65%), ulnar (13%), and both-sided (22%). There were no statistically significant differences in RTT, RTP, and UCLR by grade or tear location. However, objectively, ulnar-sided tears had the lowest RTT (81%) and RTP (42%). The ulnar (58%) and both-sided (60%) tears also had an objectively higher rate of UCLR compared to humeral sided tears (51%, p=0.441). The survivorship analysis showed a consistent decline over time with increasing MRI grade. By location, humeral tears had the highest survivorship (1 yr = 51%; 2 yr = 44%). However, there was no statistically significant differences in survivorship for either grade or location. Multivariate analysis measured the likelihood of not returning to play as 3 times higher [95% CI: 1-9.3; p=0.044] for older players (&gt;25) compared to younger players. The likelihood of having re-injury or UCLR after non-operative treatment failed was almost 6 times higher [95% CI: 1.5-21.7; p=0.012] for MLB players as opposed to MiLB players. MRI grade and tear location were not significantly predictive of returning to play, re-injury, or surgery. Conclusion: This is the largest study to evaluate the prognostic relationship of MRI injury grade and tear location with outcomes for non-operatively treated elbow UCL tears in professional baseball players. Lower MRI grade and humeral location were objectively associated with a higher RTT, higher RTP, lower UCLR, and higher survival compared to higher grade, and ulnar or both-sided tears. Older age (&gt;25) had a significantly higher likelihood of not returning to play after non-operative treatment. Competing at the MLB level had a higher likelihood of re-injury or having UCLR. Based on this study, non-operative treatment of UCL injuries will likely be more successful in younger players, lower grade tears, and humeral-sided injuries.

The Elbow UCL Injury Prognosis Score

Objectives: No model exists to predict which patients with elbow ulnar collateral ligament (UCL) injuries will successfully return to play (RTP) with non-operative treatment. The reported rates for successful RTP after non-operative management of UCL injuries are limited and vary widely. Furthermore, patient and UCL injury characteristics that influence failure of non-operative treatment have not been established. We sought to identify which factors were most significant in predicting which patients would have successful RTP after non-operative management of UCL injury. In doing so, we created the Elbow UCL Injury Prognosis Score to identify and weigh factors that predict failure of non-operative treatment. The parameters include: age, position, competition level, moving valgus stress test (MVST), 5th finger sensation, UCL tenderness, and MRI findings including tear type, location, and chronicity features. This score will predict which patients will succeed non-operative management, avoiding unnecessary surgery while simultaneously identify patients for whom non-operative management would be delaying the inevitable need for surgical intervention. Methods: 205 patients were evaluated by the senior author for a UCL injury. Physical exam findings, imaging characteristics and patient demographics were retrospectively collected and entered into a HIPAA-compliant REDCap database after IRB approval of the study design. Of these patients, 138 underwent a trial of non-operative treatment and were either cleared for RTP (n= 55) or eventually underwent surgical intervention (n= 83) after a minimum one-month trial of non-operative management. Sixty-seven patients decided to have surgery immediately without trialing non-operative management and were excluded from the scoring system. The Elbow UCL Injury Prognosis Score was developed and validated using stepwise feature selection by Akaike information criterion (AIC). Three-fold cross validation was performed using these ten variables as predictors. The mean and standard deviation of area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, positive predictive value, and negative predictive value were evaluated. Results: The area under curve for non-operative failure predicting non-operative management failure was 0.79 (0.054), with sensitivity=0.85 (0.088), specificity=0.72 (0.032), positive predictive value=0.83 (0.023), negative predictive value=0.77 (0.091) [mean (standard deviation (SD))]. Patients were predicted to succeed non-operative management if they scored less than 10, while for a score greater than or equal to 10 patients would likely fail non-operative management and require surgical intervention for their UCL injury (Table 1). Conclusion: The Elbow UCL Injury Prognosis Score is a statistically rigorous, powerful tool for predicting which patients will most likely RTP with non-operative treatment. We hope this score can provide surgeons with a useful tool to enhance and enable shared decision making with patients when faced with UCL injuries at all competitive levels. [Table: see text]

Epidemiology of Elbow Ulnar Collateral Ligament Injuries in Throwing Versus Contact Athletes of the National Collegiate Athletic Association: Analysis of the 2009-2010 to 2013-2014 Seasons.

Background:The management and outcomes of elbow ulnar collateral ligament (UCL) injuries in throwing athletes have been well investigated. However, less is known regarding the management, severity, and outcomes of such injuries in contact athletes.Purpose:To compare the incidence, severity, and outcomes of elbow UCL injuries between throwing and contact athletes in collegiate sports.Study Design:Descriptive epidemiology study.Methods:Elbow UCL injuries were queried from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program between the seasons of 2009-2010 and 2013-2014 in 25 varsity sports. The rates and distribution of injuries by mechanism, participation restriction time, and outcomes (eg, season-ending injury, surgery) were examined. A severe injury was defined as loss of ≥21 days from participation, a season-ending injury, or requiring a surgical intervention. The injury frequency, incidence per 10,000 athlete-exposures (AEs), and injury proportion ratio comparing throwing and contact athletes were calculated with 95% CIs.Results:Over the course of 5 seasons, 109 UCL injuries were recorded, for an overall injury rate of 0.29 per 10,000 AEs. Of these injuries, 83 (76.1%) were a result of contact and 26 (23.9%) from throwing. Men’s wrestling (1.78 per 10,000 AEs) and men’s baseball (1.12 per 10,000 AEs) sustained the highest injury rates. A larger proportion of throwing (n = 8; 36.4%) compared with contact (n = –7; 9.1%) (P < 0.01) injuries results in >21 days of time loss. Additionally, more throwing-related UCL injuries required surgery (n = 2; 11.1%) compared with contact-related injuries (n = 1; 1.3%) (P < 0.01). As a result, throwing athletes demonstrated a significantly higher proportion of severe injuries than contact athletes (injury proportion ratio, 4.62 [95% CI, 1.72-12.40]).Conclusion:The evaluation of athletes in 25 collegiate varsity sports across 5 seasons found over 3 times more elbow UCL injuries in contact versus throwing athletes. However, the number of severe injuries in throwing athletes was significantly higher than in contact athletes. These findings demonstrate that although elbow UCL injuries are prone to occur in both contact and throwing athletes, their prevention, management, and outcomes must be framed on a sport-by-sport basis.