UCL Injury Research Articles

The influence of sex and trauma impact on the rupture site of the ulnar collateral ligament of the thumb.

Purpose and hypothesisAlthough sex- and gender-specific analyses have been gaining more attention during the last years they have rarely been performed in orthopaedic literature. The primary purpose of this study was to investigate whether for injuries of the UCL the specific location of the rupture is influenced by sex. A secondary study question addressed the sex-independent effect of trauma intensity on the rupture site of the UCL.MethodsThis study is a retrospective analysis of all patients with either a proximal or distal bony avulsion or with a mid-substance tear or ligament avulsion of the UCL treated surgically between 1992 and 2015 at two level-I trauma centres. Trauma mechanisms leading to the UCL injury were classified into the following categories: (1) blunt trauma (i.e., strains), (2) low-velocity injuries (e.g., fall from standing height, assaults), and (3) high-velocity injuries (e.g., sports injuries, motor vehicle accidents). After reviewing the surgical records, patients were divided into three groups, depending upon the ligament rupture site: (1) mid-substance tears, (2) proximal ligament or bony avulsions and (3) distal ligament or bony avulsions. Dependencies between the specific rupture site and the explanatory variables (sex, age, and trauma intensity) were evaluated using χ2 test and logistic regression analysis.ResultsIn total, 1582 patients (1094 males, 488 females) met the inclusion criteria. Mean age was 41 years (range: 9–90 years). Taking into account the effects of sex on trauma intensity (p<0.001) and of trauma intensity on rupture site (p<0.001), mid-substance tears occurred more frequently in women, whereas men were more prone to distal ligament or bony avulsions (p<0.001). In other words, sex and rupture site correlated due to the effects of sex on trauma intensity and of trauma intensity on rupture site, but taking into account those effects there still was a significant effect of sex on rupture site.ConclusionsThe results of this study demonstrate that with regression analysis both sex and trauma intensity allow to predict rupture site in UCL injuries.

Comparison of Cyclic Fatigue Mechanics between UCL Repair with Internal Bracing and UCL Reconstruction

Objectives:UCL reconstruction has become the preferred treatment for UCL injury in elite throwers desiring a return to throwing. Prior reports of UCL repair demonstrated poor results in professional pitchers, with rate of return to the same or higher level pitching between 0% and 63%. 1,3,6,9,11 However, in young athletes without chronic attritional UCL damage, recent data shows reliable and rapid return to sport with primary UCL repair.2,12,14 We previously introduced a novel UCL repair technique consisting of primary UCL repair, augmented with a spanning tape anchored at either end of the native ligament. Compared to UCL reconstruction, this construct demonstrated significantly greater resistance to gap formation, even at low cycles of valgus loading.8 The purpose of the current study was to compare the high-cycle fatigue mechanics of augmented UCL repair versus modified Jobe UCL reconstruction. We hypothesized that the repaired specimens would have less gap formation compared to the reconstruction group after 10, 100, and 500 cycles of valgus loading.Methods:Twenty fresh-frozen cadaveric upper extremities (10 matched pairs) were dissected to expose the anterior band of the UCL.3 The humeral and ulnar insertions of the UCL were identified and marked to measure ligament displacement.7 Each specimen was potted and mounted on a mechanical test frame.4,5,8,10,13 A 2 N-m valgus preload was applied to the native elbow followed by a 60 s hold and 500 cycles of valgus loading between 2 N-m and 10 N-m. A longitudinal split in the anterior band was created and the distal attachment of the sublime tubercle was released, simulating a distal avulsion tear of the UCL. Ten cycles were repeated in this torn state. Each pair was randomly separated into either a repair or a reconstruction group (Fig 1). Each specimen was then manually subjected to 100 cycles of flexion-extension range of motion to simulate early rehabilitation protocols. The specimens were again loaded for 500 cycles between 2 N-m and 10 N-m, followed by a ramp to failure at a rate of 1°/s. Torque and rotation were recorded in addition to gap measurements for the 10th, 100th, and 500th cycle of the intact and repair/reconstruction conditions. Gaps were measured optically8 as the change in distance of the two anatomical landmarks between the pre-cycling hold and the peak of the cycle of interest. A two-way ANOVA with repeated measures was used to detect overall differences in addition to post-hoc t-tests and Tukey’s HSD for between the two procedures and three conditions, respectively. Significance was set at p ≤ 0.05.Results:The repair group showed greater resistance to gapping compared to reconstruction after 10 (p=0.008), 100 (p=0.02), and 500 (p=0.004) cycles (Fig. 2) of valgus motion. There was no difference in the intact state; however, the repair group did exhibit a reduction (p=0.007) in gap in the torn state after 10 cycles.Conclusion:In this preliminary report, UCL repair using internal bracing is more resistant to gap formation under fatigue loading than the gold standard reconstruction technique. The time-zero failure properties of this repair technique are on par with those of traditional reconstruction, although similar differences also seen in the torn state at early cycles may act as a confounding factor. In young throwers with insertional UCL injuries, our UCL repair technique may provide a suitable alternative to reconstruction with similar biomechanical properties and faster return to sport.

Electromyographic and Motion Capture Analysis of the Elbow and Forearm in the Overhead Football Throw

Objectives:Muscle activation patterns and the kinetics of overhead throwing have been well described in the baseball athlete but not in the football athlete. Injury patterns vary between these two populations. The purpose of this controlled laboratory study was to describe the muscle activation patterns of the elbow and forearm during the overhead football throw. A better understanding of muscle activation patterns and kinetics will help clinicians understand the difference in injury between these two populations, with an objective of preventing injury in both groups. The hypothesis was that the unique grip and obligatory pronation upon ball release will cause the elbow and forearm muscles to have a unique activation pattern during the overhead football throw.Methods:IRB approval was obtained. Electromyographic (EMG) and motion capture data was collected on eight male quarterbacks. An EMG direct transmission system measuring at 1200 Hz with 9 surface electrodes was used to collect EMG data, with signals normalized to maximal voluntary contraction values for each subject. EMG sensors were placed on the biceps, triceps, brachialis, brachioradialis, anconeus, extensor digitorum communis, flexor digitorum superficialis, pronator teres, and pronator quadratus. A 13 camera motion capture system measuring at 240 Hz with a full body marker set of 39 retro-reflective 9mm markers was used to capture motion data. The throwing motion was divided into four event segments: early cocking, late cocking, acceleration, and follow through.Results:All athletes had NCAA experience and were aged 18-30 years old. The anconeus (26.9%, 36.3%, 57.6%, and 105.8% MVCs), extensor digitorum communis (22.7%, 28.0%, 31.0%, and 42.8% MVCs), and flexor digitorum superficialis (19.4%, 39.3%, 22.3%, and 104.7% MVCs) had high levels of activity throughout all phases of the football throw. The brachioradialis (56.8%MVC) and anconeus (57.6%MVC) were the most active muscles during the acceleration phase. The pronator teres (78.4%MVC), pronator quadratus (90.9%MVC), and flexor digitorum superficialis (104.7% MVCs) have very high levels of activation during the follow through phase.Conclusion:High levels of activity of the anconeus suggest that it functions as a dynamic stabilizer during all phases of the throwing motion. High levels of activity of the extensor digitorum communis and flexor digitorum superficialis suggest that they are important for grip. The pronator teres and pronator quadratus are important at ball release to produce a spiral motion of the football. High activity of the medial sided musculature may impart dynamic stability to the elbow. These findings may explain why quarterbacks have a lower rate of UCL injury and a higher return to play without surgery.

Radiographic comparison of adolescent athletes with elbow osteochondritis dissecans to ulnar collateral ligament injuries and controls

There are excellent data supporting recommendations to prevent elbow injuries (osteochondritis dissecans [OCD] and ulnar collateral ligament [UCL] injuries), such as pitch count and pitch type in baseball, but anatomic risk factors have not been thoroughly examined. This study aimed to evaluate radiographic measurements in adolescents with elbow OCD lesions or UCL injuries and controls. We retrospectively identified adolescent patients between 2011 and 2016 with isolated capitellum OCD, UCL tear, or normal elbows based on magnetic resonance imaging. Nineteen patients (mean age, 13.5 years) had isolated OCD defects of the capitellum, 8 patients (mean age, 16.9 years) had isolated UCL complete tear, and the remaining 16 patients (mean age, 14.6 years) were normal controls. Radiographic measurements from corresponding anterior-posterior elbow radiographs were taken, including carrying angle, distal humeral articular surface angle, and radial neck-shaft angle. On the lateral radiograph, anterior angulation of the articular surface of distal humerus was measured. Significant differences were observed in carrying angle between controls (15.7°) and OCD patients (11.6°; P = .03) as well as between controls and UCL patients (10.3°, P = .02), with the OCD and UCL patients tending to be in more varus. Significant differences were also found between controls (88.5°) and OCD patients (93.6°; P = .01) and between controls and UCL patients (93.3°; P = .03) in distal humeral articular surface angle, with OCD and UCL patients with increased valgus at the distal humerus articular surface. There were no significant differences between groups in radial neck-shaft angle or anterior angulation of articular surface of distal humerus. Patients with OCD and UCL injuries have anatomic differences compared with normal controls that can be measured radiographically.

Risk of Fragments in Ulnar Collateral Ligament Injuries Of Baseball Players

Objectives:Many baseball players with UCL injuries have avulsed persistent fragments by throwing disorder in the youth. The presence of fragments results in discontinuity of the medial elbow joint support structures; therefore, a ligament with fragments is considered more fragile than the normal ligament. This study compared three types (fragment, malunion, and normal) of throwing-related UCL injuries and prospectively examined the risk of surgical treatment.Methods:The total subjects were 439 baseball players (age 14-30 years; mean age, 17.5 years) diagnosed with UCL injuries at our hospital between November 2009 and June 2013. At the time of the initial examination, the medial epicondyle was assessed on plain frontal radiographs with the elbow flexed at 45°. Based on this assessment, subjects were divided into three groups: group with persistent fragments (fragment [F] group), group with complete union following avulsion fracture (malunion [M] group), and a group with no history of avulsion fracture (normal [N] group). Each patient’s ability to return to playing baseball was assessed after at least 3 months of systematic rehabilitation. Subjects who failed to comply with rehabilitation, played only recreationally, or with pain in sites other than the elbow were excluded. In this series, 220 cases were left for investigation. The Conway-Jobe scale was used as a standard to assess the return to playing after conservative therapy; subjects with excellent or good ratings were deemed able to return to playing baseball, whereas those with fair or poor ratings were deemed unable to return to playing baseball. The return rates were calculated for the F, M, and N groups respectively. The Magnetic resonance (MR) images consisted of three slices along the long axis of the anterior oblique ligament; these images were used to classify injuries as severe or mild, which were then compared with each other. SPSS 20.0 was used to perform the statistical analysis.Results:A total of 107 subjects were able to resume playing competitive baseball game, whereas 113 subjects were unable to resume playing and underwent surgical treatment (Table.1). The F group demonstrated a significantly lower return rate (p < 0.01) (Table.2). The F group demonstrated a significantly higher percentage of severe injuries (p < 0.01) (Table.2).Return rates in the mild and severe injury groups were 79.1% and 29.1%, respectively, demonstrating a significant difference (p < 0.01) (Table.3). Not surprisingly, the return rate among subjects with severe injuries in the F group was a mere 14.3% (7/49).Conclusion:The results of the present study demonstrated that the presence of fragments in UCL injuries tended to increase the severity of UCL injuries and significantly reduced patient the return rates of competitive game after conservative therapy. Therefore, this exacerbation of UCL injuries is considered a result of persistent medial epicondylar fragments in young baseball players.

MRI Predictors of Failure in Non-operative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers

Objectives:Ulnar collateral injuries (UCL) of the elbow are prevalent among professional baseball pitchers. The decision on initial operative versus nonoperative management of these injuries remains subjective in many cases, with reported success rates with nonoperative management ranging from 42 to 93% in professional throwing athletes. No studies to date have identified objective characteristics specific to success or failure of nonoperative intervention. The purpose of this study was to identify radiologic predictors for success or failure in nonoperative management of ulnar collateral ligament injuries in professional pitchers.Methods:A retrospective review of pitchers sustaining UCL injuries between 2006 and 2015 from one professional baseball organization (one major league team and all minor league teams included) was performed. UCL injuries were identified in 38 players based on clinical and radiographic findings. Six players underwent initial surgical intervention without attempted nonoperative intervention and were excluded from analysis. This left 32 (84%) professional pitchers who underwent an initial trail of nonoperative treatment for partial UCL tears. Success was defined as return to same level of play (RTSP) or higher for >1 year. Failure was defined as recurrent pain or weakness requiring surgical intervention after a minimum of 3 months’ rest when attempting a return to throw rehabilitation program. MRI findings were classified as high or low grade sprains, proximal or distal location of injury, and with or without the presence of concomitant chronic findings.Results:Of the 32 patients who underwent nonoperative management, 10 (36%) failed and required subsequent ligament reconstruction. Between the success and failure groups, there was no significant difference seen in total shoulder arc of motion (P=.7776), shoulder internal rotation deficit (P=.3846) or loss in elbow extension (P=.0644) at the time of injury. When comparing MRI findings between the groups, distal tears were found in 90% (9/10) of those who failed nonoperative management compared to 18.2% (4/22) who were successful nonoperatively (P=<.0001). No significant difference was seen with high grade tears (P=.0817) between the groups. When adjusting for age, location and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 22.7 times greater (P=.001) with distal tears. No other variable reached significance, and no combination of variables showed a greater likelihood than distal location alone.Conclusion:In professional pitchers, distal ulnar collateral ligament tears described on MRI show significantly higher rates of failure with nonoperative management compared to proximal tears. This information provides an objective measure for evaluating operative versus nonoperative management of ulnar collateral ligament injuries in throwing athletes.

Ultrasound study of elbow ulnar collateral ligament changes in collegiate baseball players: A pilot study

To assess changes in elbow ulnar collateral ligament length in college baseball pitchers over the course of a single season. Cohort Feasibility Study. Diagnostic ultrasound was used to assess both the dominant and non-dominant medial elbow joint space in four pitchers and five fielders and compared to in-game pitching data. Shoulder, elbow, wrist, hip, knee, and ankle range of motion measurements were also taken. Mean trends for both the pitching and fielding groups showed no increases in dominant arm medial elbow joint space. Range of motion (ROM) increases were seen in both groups, and neither ultrasound nor ROM changes correlated to number of pitches thrown. It is feasible that shoulder and hip range of motion changes directly affect stresses at the elbow in baseball pitching (Wilk etal., 2014) (Sauers etal., 2014). Further research is needed to investigate whether UCL injuries are related to increased laxity of the ligament.

Professional Pitchers Display Differences in Ulnar Collateral Ligament Morphology and Elbow Gapping Following UCLR Compared to Uninjured Pitchers

Objectives:Ulnar collateral ligament reconstruction(UCLR) of the elbow has received much attention given the rise in incidence among all pitchers. Recent studies have demonstrated stress ultrasonography is a critical tool in the evaluation of the UCL. . No study, has dynamically evaluated the UCL in uninjured professional pitchers under stress, nor has any study evaluated the ability of UCL reconstruction (UCLR) to restore normal kinematics. The purpose of this study was to compare ulnohumeral gapping and UCL thickness in both uninjured professional pitchers and those who had undergone UCLR during a moving valgus stress test. We hypothesized that the UCL will be thicker and the ulnohumeral joint will display adaptive gapping in D arms compared to ND arms. Furthermore we hypothesized that UCLR would restore gapping and UCL morphology.Methods:Ultrasonography was used to assess the UCL of 70 asymptomatic professional baseball pitchers during spring training (history of UCLR, n=6). A 5-MHz linear-array transducer was used to capture images of the dominant (D) and non-dominant (ND) throwing elbows at the maximal cocking position under two loaded conditions within the moving valgus stress test arc:(1) gravity stress and (2)-10 lbs of valgus force using a dynamometer. Ulnohumeral gapping and UCL thickness was measured on sagittal images using the OsiriXTM platform. All measures displayed reliability with intraclass correlation coefficients (ICC) ranging from ICC(2,1)=0.94 -0.98 with Standard error of measure (SEM) of 0.14-0.26 mm for intra-rater and ICC(2,k)= 0.82-0.87; SEM=0.38-0.65mm for inter-rater reliability. Separate mixed model ANOVAs(side X UCL) were used to compare pitchers’ D and ND arm variables between those with UCLR to those who never had a UCL injury.(α=0.05)Results:The D arms of uninjured pitchers demonstrated increased gapping compared to ND arm (5.4 ± 1.2vs4.7± .86 p=0.001) Players with a UCLR demonstrated decreased gapping compared to both the ND and uninjured D arms of professional pitchers. (2.6±2.9 vs 4.2±1.2; P=0.002), Furthermore, the UCLR elbows demonstrated greater D arm ligament thickness when compared to D arms in pitchers without UCL injury history(.17±.07vs.11 ±.08;P=0.03).Conclusion:This is the first study to our knowledge evaluating stress ultrasonography of the UCL during the moving valgus stress test in professional pitchers. Our data demonstrates that the UCLR results in a thicker, stiffer construct with less medial elbow gapping than even the normal condition. Using ultrasound to evaluate the UCL it was shown to be reliable, more efficient and provides a clinically feasible method to assess UCL thickness, loaded joint gapping, and stiffness post-UCLR. Future studies may consider this approach to evaluate surgical techniques and graft types for UCL reconstruction

Return to Play and Long-Term Clinical Outcomes after Suture Anchor Repair of Thumb Ulnar Collateral Ligament Injuries in Collegiate Football Athletes

Objectives:Thumb ulnar collateral ligament injuries (UCL, gamekeeper’s thumb), their surgical treatment and the potential need for prolonged immobilization can significantly damage the careers of collegiate football athletes. Suture anchor fixation may allow quicker return to play with good clinical outcomes but has not been previously studied in this population. The goal of this study is to evaluate return to play and minimum two-year clinical outcomes in collegiate football athletes treated for thumb UCL injuries with suture anchor repair.Methods:Retrospective study. Inclusion criteria were 1) complete rupture of the thumb MCP joint UCL 2) suture anchor repair of UCL 3) collegiate football athlete 4) minimum 2 years postoperative. Data collection included chart review, return to play, and QuickDASH (including work and sport module) outcomes.Skill position players were scheduled for surgery immediately, while non-skilled position players were typically casted until the end of the season and then underwent repair. A single surgeon performed all procedures. Surgical technique was the same for all patients, which included absorbable suture anchor repair of the UCL to the thumb proximal phalanx utilizing two suture anchors. Patients were then immobilized in a thumb spica. Non-skilled position players were cleared for return to play in a cast after sutures were removed. Skilled position players were not cleared until after the cast was removed.Results:A cohort of 18 collegiate football athletes treated with suture anchor thumb UCL repair at minimum 2 years post-procedure was identified. All 18 patients (100%) were available for evaluation at average 6.0 years follow-up (range, 2.5-9.5 yrs). Nine players were skill position players (WR, TE, RB) while the remaining 9 were non-skill positions (OL, DL, LB.) Average age was 19.7 yrs (range, 18-22 yrs). Average time from injury until surgery was 27 days (range 2-105 days). Average return to play for the entire cohort was 5.4 weeks postoperatively (range, 1.5-12.0 weeks). All players returned to at least the same level of play as preoperatively (collegiate). Seven players eventually continued to play professional football. The average QuickDASH score for the entire cohort was 1.2/100 (95% CI 0.40-2.26). Average QuickDASH Work Score was 0.0/100 (95% CI 0.0-0.0) and average QuickDASH Sport Score was 0.7/100 (95% CI 0.0-1.85). Average time to surgery for skill position (n=9) players was 12 days (range 2-26 days) compared to 43 days (range 10-105) in non-skilled (n=9) position players (p = 0.025). Average return to play for skill position players was 7.0 weeks postoperatively (range 4-12 weeks) compared to 3.8 weeks (range 1.5-8.0 weeks) postoperatively in the non-skilled cohort (p = 0.027). There was no difference in average QuickDASH overall score, work score or sport score between the cohorts (Table I).Conclusion:Collegiate football athletes treated for thumb UCL injuries with dual suture anchor repair have quick return to play, reliable return to the same level of play and excellent long-term clinical outcomes. Using the described treatment protocol, skill position players have surgery earlier after injury and return to play later than non-skill position players, without any differences in final level of play or clinical outcomes. Thus, thumb ulnar collateral ligament injuries can be safely and effectively managed by football position demands.

What to Do in UCL Injuries of the Elbow When There is Osseous Involvement of the UCL

What to Do in UCL Injuries of the Elbow When There is Osseous Involvement of the UCL

I Wish I Knew Then What I Know Now

We have all probably felt that way at some point in our lives, whether in our personal matters, in business, or in our medical profession. This statement seems to apply to the story of Sandy Koufax, one of the best all-time pitchers in the history of professional baseball. Sandy Koufax was forced to retire in 1966 during the peak of his career due to severe elbow pain. He has reportedly said that his elbow hurt every time he pitched. He suffered from a suspected UCL injury. His career record was 165-87 with a career ERA of 2.76, and he was the youngest player ever inducted into the Baseball Hall of Fame. In 1974, Dr Frank Jobe performed the first UCL reconstruction on pitcher Tommy John, and the procedure became known as the “Tommy John procedure.” Tommy pitched for 14 more years after the surgery, winning more games after the surgery than before (164 compared to 124 games). As the story goes,4 Sandy Koufax had asked Dr Jobe in later years, “Why didn’t you do that on me?” Dr Jobe had responded, “We simply didn’t know what to do for them back then.” But today we do know what to do. Injuries in baseball players continue to increase and at all ages. In Major League Baseball pitchers, 67% of all injuries occur to the upper extremity, with 26% occurring to the elbow joint.7 Conte et al2 reported an elbow injury rate of 22% in major league players. Pitchers injure their elbow at a higher rate than positional players (26% compared to 16%). Youth baseball players, especially pitchers, injure their elbow at an alarming rate. Since 1998 we have seen a 2.5-times increase in elbow surgery rate in youth baseball players at our center. Not only do baseball players injure their elbow, but football players and other collision athletes sustain these injuries, too. Carlisle et al,1 examining elbow, forearm, and wrist/hand injuries in the NFL, noted that 40% of those injuries occurred to the elbow joint. Sprains of the elbow were the most frequent (21%) with offensive and defensive linemen sustaining the most elbow sprains. Kenter et al5 reported an average of 18 elbow injuries per year in the NFL, with sprains being the most frequent. The authors noted that there appears to be an increasing trend of elbow injuries in the NFL. Overuse injuries occur at the elbow joint, with tendinitis being the most frequently seen and often most difficult to treat. In tennis players, approximately 40% have reported current or previous complaints of overuse tendinitis. Patients above the age of 50 years described their pain as severe and disabling.3 Tennis elbow is common, especially in individuals over 40 years of age, where there is a 4-times increase among men and a 2-times increase among women. These lesions are often challenging to treat. The elbow joint is an “unforgiving joint,” as stated by Dr Morrey in his classic elbow joint textbook.6 This is due to the high incidence of joint stiffness, loss of motion complications following fractures, dislocations, and other injuries. In this special issue of Sports Health, we have compiled some of the experts in the area of recognition and treatment of elbow disorders in sports. With elbow injuries in youth baseball players being so common, there is an article discussing factors to reduce the elbow injury rate. We hope that the knowledge and expertise shared by these authors will help us all to better treat the elbow joint today and reduce the frequency of us saying, “I wish I knew then what I know now.”