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Prevalence of Ulnar Collateral Ligament Surgery in Professional Baseball Players

Authors:
  • American Sports Medicine Institute
  • Champion Sports Medicine

Abstract and Figures

While the high rate of ulnar collateral ligament (UCL) injuries in professional baseball is widely discussed in the media and medical literature, the actual prevalence of UCL reconstruction has not been documented. The prevalence of UCL reconstruction will be higher among pitchers than nonpitchers, and Major League Baseball (MLB) pitchers will have a higher prevalence than will minor league pitchers. Descriptive epidemiology study. An online questionnaire was distributed to all 30 MLB organizations. Certified athletic trainers from each team administered the questionnaire to all players in the organization, including major league players and 6 levels of minor league players. Demographic data were compared between major and minor league players. Continuous variables (age, years of professional baseball, country of origin, etc) were compared with Student t tests (P < .05). Categorical variables (level, position, etc) were compared using chi-square analysis (P < .05). A total of 5088 professional baseball players (722 major league and 4366 minor league) participated in the survey. Pitchers represented 53% of all players, and 497 players reported at least 1 UCL reconstruction, demonstrating a prevalence rate of 10% (497 of 5088). Pitchers reported a significantly higher prevalence of UCL reconstruction (16%; 437 of 2706) than nonpitchers (3%; 60 of 2382; P < .001). Among major league pitchers, 25% (96 of 382) had a history of UCL reconstruction, while minor league pitchers showed a 15% (341 of 2324) prevalence (P < .001). Major league pitchers were also significantly older (28.8 ± 3.9 years) than minor league pitchers (22.8 ± 3.0; P < .001). The majority of major leaguers (86%) had their UCL reconstruction as professional pitchers, whereas the majority of minor league pitchers (61%) underwent their UCL reconstruction during high school and college (P < .001). The rates of UCL revision, prior elbow surgery, prior shoulder surgery, and types of UCL graft were similar between the major league and minor league pitchers. No difference in prevalence was shown between pitchers born in the United States versus Latin American countries. Pitchers have a high prevalence of UCL reconstruction in professional baseball, with 25% of major league pitchers and 15% of minor league pitchers having a history of the surgery. © 2015 The Author(s).
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Prevalence of Ulnar Collateral Ligament
Surgery in Professional Baseball Players
Stan A. Conte,
*
y
PT, DPT, ATC, Glenn S. Fleisig,
z
PhD, Joshua S. Dines,
§
MD,
Kevin E. Wilk,
z||
PT, DPT, Kyle T. Aune,
z
MPH, Nancy Patterson-Flynn,
y
MS, ATC,
and Neal ElAttrache,
y{
MD
Investigation performed at the Los Angeles Dodgers, Los Angeles, California, USA
Background: While the high rate of ulnar collateral ligament (UCL) injuries in professional baseball is widely discussed in the
media and medical literature, the actual prevalence of UCL reconstruction has not been documented.
Hypothesis: The prevalence of UCL reconstruction will be higher among pitchers than nonpitchers, and Major League Baseball
(MLB) pitchers will have a higher prevalence than will minor league pitchers.
Study Design: Descriptive epidemiology study.
Methods: An online questionnaire was distributed to all 30 MLB organizations. Certified athletic trainers from each team admin-
istered the questionnaire to all players in the organization, including major league players and 6 levels of minor league players.
Demographic data were compared between major and minor league players. Continuous variables (age, years of professional
baseball, country of origin, etc) were compared with Student ttests (P\.05). Categorical variables (level, position, etc) were com-
pared using chi-square analysis (P\.05).
Results: A total of 5088 professional baseball players (722 major league and 4366 minor league) participated in the survey. Pitch-
ers represented 53% of all players, and 497 players reported at least 1 UCL reconstruction, demonstrating a prevalence rate of
10% (497 of 5088). Pitchers reported a significantly higher prevalence of UCL reconstruction (16%; 437 of 2706) than nonpitchers
(3%; 60 of 2382; P\.001). Among major league pitchers, 25% (96 of 382) had a history of UCL reconstruction, while minor league
pitchers showed a 15% (341 of 2324) prevalence (P\.001). Major league pitchers were also significantly older (28.8 63.9 years)
than minor league pitchers (22.8 63.0; P\.001). The majority of major leaguers (86%) had their UCL reconstruction as profes-
sional pitchers, whereas the majority of minor league pitchers (61%) underwent their UCL reconstruction during high school and
college (P\.001). The rates of UCL revision, prior elbow surgery, prior shoulder surgery, and types of UCL graft were similar
between the major league and minor league pitchers. No difference in prevalence was shown between pitchers born in the United
States versus Latin American countries.
Conclusion: Pitchers have a high prevalence of UCL reconstruction in professional baseball, with 25% of major league pitchers
and 15% of minor league pitchers having a history of the surgery.
Keywords: UCL; ulnar collateral ligament revision; Tommy John surgery; pitchers; Major League Baseball
Throwing elbow injuries are common at all levels of baseball,
andrecentreportssuggestthattheseinjuriesmayevenbe
on the rise.
4,11,14
Studies utilizing the Major League Baseball
(MLB) disabled list have shown that elbow injuries represent
between 16% and 22% of all MLB injuries.
5,19
These injuries
havebeenshowntoresultinanaverageof4451lostdaysper
MLB season.
5
Ulnar collateral ligament (UCL) injuries are
a common problem in the throwing athlete and account for
a large percentage of days lost because of elbow injury. By
far, baseball exhibits the highest incidence of UCL injuries
requiring surgical reconstruction.
4,12
Throwing is particu-
larly stressful on the UCL, placing large amounts of valgus
torque across the medial elbow.
3,8,10,11,18
This opening stress
of the medial elbow peaks near the instant of maximum
shoulder external rotation and the arm’s acceleration phase
of throwing.
3,8,10,11,18
This stress appears to be the greatest
in professional baseball pitchers.
11,13
Numerous studies have documented successful out-
comes in both the short term and the long term after
UCL reconstruction in baseball players and other athletes,
with return-to-play rates approaching as high as
90%.
2,4,6,7,9,14,15,17
A recent study by Makhni et al
17
*
Address correspondence to Stan A. Conte, PT, DPT, ATC, Los
Angeles Dodgers, 1000 Elysian Park, Los Angeles, CA 90045, USA (email:
scontept@aol.com).
y
Los Angeles Dodgers Baseball Organization, Los Angeles, California,
USA.
z
American Sports Medicine Institute, Birmingham, Alabama, USA.
§
Hospital for Special Surgery, New York, New York, USA.
||
Champion Sports Medicine, Birmingham, Alabama, USA.
{
Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, USA.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 43, No. 7
DOI: 10.1177/0363546515580792
Ó2015 The Author(s)
5-in-5
1764
reported that among MLB players, performance declines
after UCL reconstruction similar to the typical decline
over time of a cohort of age-matched healthy pitchers.
Pitchers with a history of UCL reconstruction also exhibit
an increased risk of future time on the disabled list for
elbow injury. Controversy exists among baseball players,
baseball organizations, the medical community, mass
media, and the general public about the actual prevalence
of UCL reconstruction in baseball, how the numbers have
increased in recent years, why so many players (particularly
pitchers) are injuring their elbows and tearing their UCLs,
and whether pitchers are too anxious to have a UCL recon-
struction. Surprisingly, the prevalence of UCL reconstruc-
tive surgery in baseball has not been documented.
Therefore, the purpose of this study was to document the
prevalence of UCL reconstructions in professional baseball
players. It was hypothesized that the prevalence would be
much higher among pitchers when compared with nonpitch-
ers. Data were also analyzed with respect to playing level,
age, and country of origin. These findings can improve our
understanding of UCL injuries in professional baseball,
including the subgroups particularly affected, as well as
serve as a baseline to assess whether the prevalence of
UCL reconstructions decreases or increases in the future.
METHODS
This study was conducted after it was reviewed and
approved by MLB and the Major League Baseball Players
Association. An online questionnaire for minor league
players not on the 40-man roster was distributed to all
30 MLB organizations during July and August of the
2012 baseball season. A similar online questionnaire was
also sent to all 30 MLB organizations in April and May
of 2013 for the players on the 40-man roster. Certified ath-
letic trainers from each team administered the question-
naire to all players in the organization, including the
major league players and 6 levels of minor league players:
AAA, AA, High A, Low A, High Rookie, and Low Rookie.
The questionnaire consisted of 8 to 26 questions based on
whether the player had no history of UCL reconstruction
(8 questions), a single UCL reconstruction (20 questions),
or multiple UCL reconstructions (26 questions). Two ver-
sions of the questionnaire were available per the player’s
preferred language, English or Spanish. For inclusion in
the study analysis, players were required to answer all
applicable questions pertinent to their subgroup.
Statistical analyses were performed with JMP 10 (SAS
Institute Inc). Demographic data were compared between
major league and minor league players. Preliminary anal-
ysis confirmed that pitchers were much more likely to have
undergone previous UCL reconstruction (P\.001), and for
this reason UCL reconstruction prevalence was further
analyzed among only pitchers. Variables were also com-
pared between major league and minor league pitchers.
Continuous variables (age, years of professional baseball,
etc) were compared with Student ttests (P\.05). All cat-
egorical variables (level, position, etc) were compared
using a chi-square analysis (P\.05).
RESULTS
Demographics of the participants in this investigation are
shown in Table 1. There were 5088 professional baseball
players, including 722 major league players and 4366
minor league players. An estimated 5700 players were
offered to complete the survey, thus resulting in an 89%
response rate. The minor league population consisted of
643 AAA, 673 AA, 1739 A, and 1311 Rookie players. The
major league players were significantly older and had
more professional baseball experience than did the minor
league players. Pitchers represented 53% of all players.
The majority of players were from the United States
(US), with a significant minority of players from the
Dominican Republic and Venezuela.
Among the 5088 respondents, 497 had undergone at
least 1 UCL reconstruction. Thus, the prevalence of profes-
sional baseball players including pitchers and position
players who had UCL surgery was 10% (497 of 5088).
The prevalence of UCL reconstruction was much higher
in pitchers (16%) than in nonpitchers (3%). Among pitch-
ers, the prevalence of UCL reconstruction was higher in
major league pitchers, older pitchers, and current relief
pitchers (Table 2). There was no difference in prevalence
between left- and right-handed pitchers nor between US-
born and international pitchers. When the subgroups of
international pitchers born in the Dominican Republic or
all Latin American countries were compared with pitchers
from the US, there was still no difference in UCL recon-
struction prevalence.
As shown in Table 3, there were several differences
between the major league and minor league pitchers with
a history of UCL reconstruction. The major league pitchers
were significantly older (P\.001) with more years of pro-
fessional baseball experience. The average age for first
UCL reconstruction was also higher in major league
TABLE 1
Demographics of All Players
a
Major League
Players
(n = 722)
Minor League
Players
(n = 4366) P
Age, y 28.8 63.9 22.8 63.0 \.001
Professional baseball, y 8.8 64.0 3.9 62.9 \.001
Current age, y \.001
\21 \1 (3) 20 (858)
21-25 18 (128) 65 (2858)
26-30 54 (387) 13 (548)
31-35 22 (157) 2 (86)
.35 7 (47) 0 (16)
Position .87
Pitcher 53 (382) 53 (2324)
Nonpitcher 47 (340) 47 (2042)
Country of origin .14
United States 73 (526) 71 (3119)
Dominican Republic 10 (72) 13 (533)
Venezuela 8 (57) 7 (286)
Other 9 (67) 9 (407)
a
Values are presented as mean 6SD or % (n).
Vol. 43, No. 7, 2015 Prevalence of UCL Surgery in Professional Baseball 1765
pitchers. The majority of major leaguers (86%) had their
UCL reconstruction as professional pitchers, whereas the
majority of minor league pitchers (61%) underwent their
UCL reconstruction during high school. The rates of UCL
revision, prior elbow surgery, prior shoulder surgery, and
types of UCL graft were similar between the major league
and minor league pitchers. Ulnar nerve transposition was
performed in a majority of pitchers who underwent UCL
reconstruction (71%). Other commonly performed concom-
itant procedures were bone spur removal (33% of all pitch-
ers) and loose body removal (14%).
The outcome results portion of the questionnaire for
pitchers who underwent UCL reconstruction are shown
in Table 4. All players in the UCL reconstruction group
were asked about their perception regarding their current
throwing velocity. Because previous studies suggested that
it takes 12 to 18 months for players to return to their pre-
vious levels of play after UCL reconstruction, responses
were excluded for this question among players who had
undergone their primary UCL reconstruction during the
past 12 months. When asked, ‘‘If you had to, would you
have Tommy John surgery again?’’ 72% of the players in
the UCL reconstruction group responded that they would,
17% said that they would not, and 11% were unsure. Minor
league pitchers were more likely than major league pitch-
ers to have self-reported higher throwing velocity after
their surgery but were less likely to state that they would
undergo UCL reconstruction again.
DISCUSSION
Despite an increasing body of literature being written on
the topic of UCL reconstructions in baseball players, there
has not been a study documenting the prevalence of UCL
reconstructive surgery among professional baseball play-
ers. Single-center studies have done an excellent job in
reporting their follow-up findings, with Cain et al
4
report-
ing on the largest number of athletes after UCL recon-
struction to date.
2,4,6,7,16,17
However, even the Cain et al
study did not elucidate the number of players in profes-
sional baseball who had undergone reconstruction of their
UCLs. In the current investigation, the overall prevalence
of UCL reconstruction among professional baseball players
was 10%. Not surprisingly, the majority of the UCL surger-
ies (88%) were performed on pitchers. In analyzing only
pitchers, 16% had UCL reconstruction surgery. During
the time of this study, the prevalence was 14% (161 of
1176) among starting pitchers and 18% (276 of 1530)
among relief pitchers. These group percentages were sur-
prisingly similar given that there is so much debate over
which type of pitcher is at higher risk to incur a tear of
his UCL. Although the prevalence of UCL reconstruction
was higher among active relief pitchers when compared
with active starting pitchers, 51% (220 of 433) of the pitch-
ers with a history of UCL reconstruction were starters at
the time of injury. Sixty-one current relief pitchers were
starting pitchers at the time that they sustained their
UCL injuries, while only 1 current starting pitcher was
a relief pitcher at the time of his UCL injury.
Whereas the overall prevalence of UCL reconstructions
among pitchers was 16%, the rates were higher among
major league pitchers and among older pitchers. Since
major leaguers were older in general, a worthwhile ques-
tion is whether the higher prevalence among major league
TABLE 2
Prevalence of Ulnar Collateral Ligament
Reconstruction Among Pitchers
Prevalence, % (n) P
Current level \.001
Major league 25 (96 of 382)
Minor league 15 (341 of 2324)
Current age, y \.001
21-25 14 (235 of 1698)
26-30 27 (132 of 484)
31-35 36 (39 of 108)
Current role .002
Starting pitcher 14 (161 of 1176)
Relief pitcher 18 (276 of 1530)
Throwing hand .26
Right-handed 17 (328 of 1969)
Left-handed 15 (109 of 737)
Country of origin
United States 16 (322 of 2007)
Not United States 16 (115 of 699) .81
a
Latin America 16 (91 of 577) .87
a
Dominican Republic 16 (54 of 343) .89
a
a
Pvalue based on comparison with ‘‘United States.’’
Figure 1. Prevalence of ulnar collateral ligament (UCL)
reconstruction for various age groups and levels. The height
of each column represents the prevalence of UCL recon-
struction among pitchers in each league within each age
group, and the width of each column is representative of
the total number of pitchers in each league within each age
group. UCL prevalence increased with age group (21-25 vs
26-30 vs 31-35 years), with no interaction between levels
(major vs minor leagues) within each age group.
1766 Conte et al The American Journal of Sports Medicine
pitchers can be attributed solely to age. Figure 1 shows
UCL prevalence for various age groups of major and minor
league pitchers. A Cochran-Mantel-Haenszel stratification
by age group (21-25 vs 26-30 vs 31-35 years) of UCL recon-
struction prevalence revealed no significant differences
between major and minor league pitchers (P= .55). How-
ever, the question of age and UCL injury certainly requires
further examination.
A topic receiving attention in the media is the appar-
ently increasing number of younger athletes requiring
UCL reconstruction. Much of this media commentary is
based on the work of Fleisig and Andrews,
11
who reported
a significant increase in UCL reconstruction surgery in
youth baseball players during the past 15 years. In the cur-
rent investigation, the overall prevalence of UCL recon-
structions in baseball players younger than 20 years was
5%. When we look at the minor league players in isolation
(which is statistically a younger aged population), the cur-
rent study demonstrated that 30% of minor league players
underwent UCL reconstruction before the age of 20 years
(including one who was 14 and one who was 15 years
old), echoing the results of Fleisig and Andrews. While
TABLE 3
Comparison of Major and Minor League Pitchers With a History of UCL Reconstruction
a
Major League Pitchers Minor League Pitchers P
Current age, y 28.7 63.8 22.8 62.7 \.001
Professional experience, y 8.4 64.0 3.8 62.7 \.001
At time of first UCL reconstruction
Age, y 24.0 64.1 21.0 62.8 \.001
Level \.001
High school 6 (6 of 96) 61 (205 of 338)
College 7 (7 of 96) 30 (103 of 338)
Professional 86 (83 of 96) 9 (30 of 338)
Position .064
Starting pitcher 59 (57 of 96) 48 (163 of 337)
Relief pitcher 41 (39 of 96) 52 (174 of 337)
No. of UCL reconstructions .71
1 97 (93 of 96) 98 (333 of 341)
2 3 (3 of 96) 2 (8 of 341)
Graft (first UCL reconstruction) .60
Forearm–throwing arm 59 (55 of 94) 60 (198 of 330)
Forearm–nonthrowing arm 14 (13 of 94) 13 (44 of 330)
Leg 27 (25 of 94) 22 (74 of 330)
Other/don’t know 1 (1 of 94) 4 (14 of 330)
Surgery before first UCL reconstruction
Elbow 11 (11 of 96) 7 (25 of 338) .21
Shoulder 9 (8 of 94) 4 (15 of 335) .13
a
Values are presented as mean 6SD or % (n). UCL, ulnar collateral ligament.
TABLE 4
Outcomes for Pitchers With UCL Reconstruction
a
Major League Pitchers Minor League Pitchers P
Surgery since primary UCL reconstruction
Shoulder 11 (10 of 94) 5 (17 of 335) .057
Elbow 9 (9 of 96) 11 (36 of 335) .85
Current velocity vs that before primary UCL reconstruction .004
Faster 26 (20 of 77) 46 (111 of 239)
Same 1 (1 of 77) 1 (3 of 239)
Slower 51 (39 of 77) 42 (101 of 239)
Don’t know 22 (17 of 77) 10 (24 of 239)
If had to, would have UCL reconstruction again
b
.047
Yes 86 (65 of 76) 72 (171 of 239)
No 9 (7 of 76) 16 (39 of 239)
Don’t know 5 (4 of 76) 12 (29 of 239)
a
Values are presented as % (n). UCL, ulnar collateral ligament.
b
Includes only responses from players with primary UCL reconstruction at least 12 months before survey.
Vol. 43, No. 7, 2015 Prevalence of UCL Surgery in Professional Baseball 1767
this highlights the fact that UCL reconstructive surgeries
are being done on younger patients, it also indicates that
the surgery is often successful enough to allow these ath-
letes to excel to the highest level of baseball even after
a major surgical reconstruction. To this point, Osbahr
et al
18
evaluated the outcomes after UCL reconstruction
in competitive baseball players at a minimum 10-year fol-
low-up. They found that 83% of athletes (90% of pitchers)
were able to return to baseball in \1 year and that after
surgery, the average baseball career was 3.6 years. More
to our point, professional baseball players returned for lon-
ger than college or high school athletes. What remains
unknown is how many teenage baseball players undergo
UCL reconstruction and are subsequently unable to reach
the level of professional participation or even return to their
prior levels of function. A large multisite prospective study
would be needed to determine the long-term clinical out-
comes of UCL reconstruction in teenage athletes.
Another issue that is frequently discussed in the media
is whether UCL reconstruction is a problem preferentially
affecting US-born athletes.
20
Despite news articles stating
this to be the case, the results of the current study clearly
show this to be false and that the prevalence of UCL recon-
struction is equal between US and Latin American players.
One difference that was noted to be statistically significant
(P\.001) was that there was a much larger percentage of
Dominican Republic pitchers who underwent their first
UCL reconstruction at the professional level when com-
pared with pitchers from the US (96% vs 56%). However,
there was no difference between the average ages of the
first UCL reconstructive surgery between these 2 groups
(21 years of age). This was also true when pitchers from
all Latin American countries were compared with the
pitchers from the US.
When a pitcher returns to throwing after shoulder sur-
gery, there is often concern about potential elbow injury
owing to altered throwing mechanics and incomplete reha-
bilitation. This survey indicated that only 9% of the UCL
reconstruction group had any previous elbow surgery and
only 5% had previous shoulder surgery. Given the limita-
tions of the study, we do not have details regarding any
prior surgeries. However, the players who had undergone
previous surgeries represent a very small number of the
study population, so on the basis of these data, it appears
that previous elbow or shoulder surgery is not a significant
risk factor for subsequent UCL reconstruction.
Of the players who had a UCL reconstruction, 10% had
an additional elbow procedure later in their careers, and
only 6% underwent a shoulder surgery. These are encour-
agingly low values that represent a minimal risk of addi-
tional injury after a return to throwing after UCL
reconstruction. Cain et al
4
reported that 7% of their
patients with UCL reconstruction underwent a subsequent
elbow procedure, with the most common one being the
removal of an olecranon osteophyte. They also reported
a 3% incidence of a shoulder surgery after the UCL recon-
struction. The most likely reason for these findings can be
attributed to adequate and complete rehabilitation after
UCL reconstruction. While our study looked at the risk of
future surgery after UCL reconstruction, it is important
to note that this underestimates the risk of future injury
after UCL reconstruction. The study by Makhni et al
17
revealed that 57% of pitchers undergoing UCL reconstruc-
tion returned to the disabled list after surgery because of
injury to their throwing arms.
A major concern regarding players undergoing UCL
reconstruction is whether their performance will be
reduced after the surgery. Along these lines, Makhni
et al
17
reviewed 147 cases of MLB pitchers who underwent
UCL reconstruction and returned to MLB. Eighty percent
returned to pitch at least 1 MLB game. However, only 67%
returned to their prior levels of competition, and even more
discouraging was the fact that 57% returned to the dis-
abled list after the surgery because of injury to their throw-
ing arms. Additionally, in contrast to other reports,
performance declined after surgery.
17
In our current survey, we did query about throwing
velocity. Admittedly, this was based solely on the athlete’s
own perception, which may be inaccurate. We included
the results because physicians treating these athletes are
often asked if the athlete will throw harder after surgery,
and a significant proportion of athletes and coaches believe
that performance is enhanced by the procedure.
1
In fact,
41% of the players who underwent UCL reconstruction
reported throwing faster after surgery, while 44% reported
throwing slower after surgery. However, this study does
not include players who were unable to return to profes-
sional baseball after UCL reconstruction. If this group of
players were to be included, it is likely that the percentage
(41%) of respondents reporting that they were able to throw
faster after UCL reconstruction would be lower.
There exist several limitations to this study. It is vital to
recognize that this study reported the prevalence, not the
incidence, of UCL reconstruction in professional baseball.
Professional baseball players who had UCL reconstruction
but are no longer in professional baseball were not
included. Results from this study—particularly, the out-
comes reported in Table 4—could be different if players
who did not return and stay in professional baseball were
included. A prospective longitudinal study is needed to quan-
tify the incidence of UCL injuries and outcomes after all UCL
reconstructions. Furthermore, the prevalence of UCL recon-
struction was determined by self-report, which may have
introduced misclassification bias. Ideally, we would have
compared participants’ responses with their medical records.
Unfortunately, this was not possible. It is our belief, however,
that because Tommy John surgery is so common among
baseball players and requires such a long, unique rehabilita-
tion protocol, professional baseball players’ recollections of
what elbow surgery they underwent are unlikely to be too
disparate from their medical records. Players were given
the option of an English or Spanish version of the question-
naire, and a small number of players in the study were
from countries that did not speak either language fluently.
The survey was administered by the given player’s certified
athletic trainer, who was able to ensure understanding and
completion of every question. Players who were not able to
understand or complete every question were excluded.
Clearly, the strength of this study is that it reported on
a homogeneous group of .5000 professional baseball players,
1768 Conte et al The American Journal of Sports Medicine
with an estimated 89% of eligible players completing the sur-
vey. A perceived increased frequency of UCL reconstruction
in professional baseball has drawn much attention from
the medical community, press media, and general public,
but the current study is the first to report the true prevalence
of UCL reconstruction in professional baseball. Since any
past prevalence is unknown, a historical rise in UCL recon-
struction rates cannot be confirmed. However, this study
showed a current prevalence of 16% among professional
pitchers and 3% among nonpitchers. These numbers provide
a perspective of the effect that UCL reconstructions have on
professional baseball today and so can serve as a baseline for
assessing future increases or decreases in UCL surgery
rates.
ACKNOWLEDGMENT
The authors thank K. C. Cord for her assistance in the sur-
vey design, as well as Major League Baseball and the ath-
letic trainers of the Professional Baseball Athletic Trainers
Society for the collection of the data. A special thanks to
Michael Weiner, executive director of the Major League
Baseball Players Association. Without the advice and sup-
port of the late Dr Lewis Yocum, this article would not
have been possible.
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Vol. 43, No. 7, 2015 Prevalence of UCL Surgery in Professional Baseball 1769
... 5,12,25 The prevalence of UCLR among MLB pitchers has increased in the past 15 years. 8 In a recent study, 3 we demonstrated that a higher proportion of UCL-injured MLB pitchers who underwent UCLR from 2007 to 2017 used the TF pitching style compared with the DD style (72.6% vs 27.4%, respectively). Nonetheless, it is unknown what proportion of MLB pitchers use the TF and DD pitching styles and whether either of these pitching styles elicits a greater rate of UE injury or UCLR. ...
Article
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Background Previous research has documented the proportion of “tall and fall” (TF) and “drop and drive” (DD) pitching styles among Major League Baseball (MLB) pitchers who underwent ulnar collateral ligament reconstruction (UCLR). The proportion of these 2 styles among all MLB pitchers remains unknown. Purpose To determine the proportion of the TF and DD pitching styles in all rostered MLB pitchers during a single season as well as the proportion of TF and DD pitchers who sustained an upper extremity (UE) injury and those who underwent UCLR. Study Design Cross-sectional study; Level of evidence, 3. Methods Pitcher demographic characteristics from the 2019 MLB season and pitching information were obtained via open-access sources. Two-dimensional video analysis was used to categorize the included pitchers into TF and DD groups. Statistical comparisons and contrasts were made using 2-tailed t tests, chi-square tests, and Pearson correlation analyses as appropriate. Results Of the 660 MLB rostered pitchers in 2019 (age, 27.39 ± 3.51 years; body mass index, 26.34 ± 2.47 kg/m ² ; fastball velocity, 150.49 ± 3.99 kph [93.51 ± 2.48 mph]), 412 (62.4%) pitchers used the TF style and 248 (37.6%) pitchers used the DD style. Significantly more UE injuries were seen in the TF group compared with the DD group (112 vs 38 injuries, respectively; P < .001). Twelve pitchers underwent UCLR (TF, 10; DD, 2), representing a 1.8% UCLR rate among all pitchers. This was a second surgery for 2 pitchers, both of whom used the TF pitching style. Significantly more pitchers in the TF group than the DD group had undergone UCLR before 2019 (135 vs 56 pitchers, respectively; P = .005). Conclusion The results of the present study demonstrated a higher prevalence of both UE injury and prior UCLR in TF pitchers. Further research is needed to explore the potential association between pitching style and UE injury.
... Along with concerns for tensile damage to other medial structures (i.e., flexor-pronator mass, ulnar nerve), VEO can also lead to radiocapitellar compression, potentially resulting in the development of loose bodies, as well as olecranon fossa shearing with resultant posterior compartment osteophytes and/or loose body generation. [1][2][3][4] Such osteoarthritic changes and loose bodies may cause pain, dysfunction, and mechanical symptoms that result in continued morbidity after UCL reconstruction (UCLR) and possible need for reoperation. Athletes with posteromedial impingement (PI) are commonly treated with concomitant arthroscopic resection of posteromedial osteophytes at the time of index UCLR 5-10 to mitigate these risks. ...
Article
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Purpose: The purpose of this study was to compare patient-reported outcomes and return to play (RTP) rates following ulnar collateral ligament reconstruction (UCLR) in patients with and without posteromedial elbow impingement (PI) treated with concomitant arthroscopic posteromedial osteophyte resection. Methods: Baseball players who underwent UCLR performed by the senior surgeon with minimum follow-up of 2 years were surveyed in this retrospective cohort study. Primary outcomes included Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, Andrews-Timmerman score, and RTP rate. Secondary outcomes included patient satisfaction scores. Results: 35 baseball players were included. Eighteen had no preoperative impingement (mean age: 19.06 ± 3.28 years), while 17 had PI treated with concomitant arthroscopic osteophyte resection (mean age: 20.06 ± 2.68 years). Following surgery, there was no difference in mean Andrews-Timmerman score (no impingement = 91.67 ± 8.04 vs PI = 92.06 ± 7.92, P = .89) nor KJOC score (no impingement = 83.36 ± 11.72 vs PI = 79.88 ± 12.35, P = .40), but there was a decreased mean KJOC throwing control sub-score in the PI group (7.65 ± 2.40 vs 9.11 ± 1.32, P = .04). There was no difference in RTP rate between the groups (no impingement = 72.22%, PI = 94.12%, χ2 = 1.28; P = .26). There was significantly higher mean satisfaction score in the no impingement group (96.67 ± 4.58 vs 90.12 ± 11.91; P = .04), and those patients were also more likely to pursue surgical treatment again (94.44% vs 52.94%, χ2 = 7.88; P = .005). Conclusions: There was no difference in RTP rate following ulnar collateral ligament reconstruction in baseball players with and without posteromedial impingement treated with arthroscopic resection. Outcomes on the KJOC and Andrews-Timmerman scores were good to excellent in both groups. Players in the posteromedial impingement group were less satisfied with their outcome, however, and less likely to elect for surgery if they were to sustain the injury again. Additionally, players in the posteromedial impingement group were found to have decreased throwing control on the KJOC questionnaire, which may suggest that the presence of posteromedial osteophytes represent adaptive changes to stabilize the elbow while throwing. Level of evidence: Level III, retrospective cohort study.
... Ulnar collateral ligament (UCL) injury commonly occurs in baseball players, particularly pitchers. In total, 25% of Major League Baseball pitchers undergo UCL reconstruction during their careers, 11 and the risk has been increasing in recent decades. 7,10 The high risk of injury is attributed to the inherent pitching motion in baseball that produces a high and repeated force on the elbow. ...
Article
Background: Baseball pitching induces a large elbow valgus load, stressing the ulnar collateral ligament. Flexor-pronator mass contraction contributes to valgus stability; however, repetitive baseball pitching may weaken the flexor-pronator mass contractile function. The present study investigated the effects of repetitive baseball pitching on the medial valgus stability measured using ultrasonography. We hypothesized that repetitive pitching would decrease elbow valgus stability. Methods: This was a controlled laboratory study. Fifteen young male baseball players at the collegiate level (age: 23.0 ± 1.4 years) were enrolled. The medial elbow joint space was measured using ultrasonography (B-mode, 12-MHz linear array transducer) in the following three conditions: at rest (unloaded), under 3 kg valgus load (loaded), and under valgus load with maximal grip contraction to activate flexor-pronator mass (loaded-contracted). All measurements were performed before and after the pitching tasks, which comprised five sets of 20 pitches. Two-way repeated-measures analysis of variance was applied to determine changes in the medial elbow joint space. The post-hoc test with Bonferroni adjustment was applied to assess the changes within the time and condition. Results: The medial elbow joint space was significantly greater under the loaded than the unloaded and loaded-contracted conditions both before- and after- pitching (p < 0.001). In the loaded-contracted condition, the medial elbow joint space significantly increased after repetitive baseball pitching (p < 0.001). Conclusions: The results of the present study indicated that repetitive baseball pitching reduced the elbow valgus stability. This reduction could be attributed to the decreased flexor-pronator mass contractile function. Insufficient contraction may increase the tensile load on the ulnar collateral ligament with pitching. Flexor-pronator mass contraction plays a role in narrowing the medial elbow joint space; however, repetitive baseball pitching reduced the elbow valgus stability. It has been suggested that sufficient rest and recovery of the flexor-pronator mass function are required to reduce the ulnar collateral ligament injury risk.
... 6,12 The greatest injury incidence is to the shoulder and elbow, with pitchers having a higher injury incidence and prevalence than position players. 6,9,11,41 These injuries have a high health care cost, 26 incur work time loss, 10 and inhibit performance. 40 Due to the severity and burden of baseball arm injuries, 6,12,26 baseball organizations have attempted to initiate injury risk and injury prevention programs. ...
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Background: Risk profiling and education are strategies implemented to help reduce injury risk; however, currently. there is little evidence on the effect of these interventions on injury incidence. The purpose of this study was to evaluate the influence of risk profiling and education on upper extremity injury incidence in minor league (MiLB) pitchers and to stratify by injury severity. Methods: A prospective natural experiment study was conducted from 2013 to 2019 on MiLB pitchers. Beginning in the 2015 season, pitchers were examined and risk profiled for upper extremity injury. Shoulder external, internal, total range of motion, horizontal adduction, and humeral torsion were measured. Organizational risk profiling and education was implemented starting in 2015, based on preseason assessments. Chi-squared test was performed to investigate potential differences between shoulder range of motion risk categories between 2013-2014 (pre) and 2015-2019 (post) seasons. Interrupted time series analyses were performed to assess the association between organizational risk profiling and education on arm injury in MiLB pitchers and were repeated for 7-27 and 28+ day injury severity. Results: 297 pitchers were included (pre: 119, post: 178). Upper extremity injury incidence was 1.5 injuries per 1000 athletic exposures. Pitchers in the 2015-2019 seasons demonstrated increased preseason shoulder injury risk for internal (P = .003) and external (P = .007), while the 2013-2014 seasons demonstrated greater horizontal adduction risk (P = .04). There were no differences between seasons for total range of motion risk (P =.76). Risk profiling and education resulted in an adjusted time loss upper extremity injury reduction for the 2015-2019 seasons (0.68 (95% CI: 0.47, 0.99)), which impacted 7-27 days (0.62 (95% CI: 0.42, 0.93)) but not for 28+ days (0.71 (95% CI: 0.47, 1.06)) time loss. There was no reduction in combined trunk and lower extremity injuries for the 2015-2019 seasons (1.55 (95% CI: 0.79, 3.01)). Conclusions: Organizational risk profiling and education appear to reduce professional pitching overall and 7-27-day upper extremity injury risk by 33%-38%. There was no difference in trunk and lower extremity injuries over the period, strengthening the reduction in upper extremity injury risk results. This suggests that while injury risk increased over time, organizational risk profiling mitigated the expected increase in upper extremity injury rates. Risk profiling and education can be used as a clinical screening and intervention tool to help decrease upper extremity injuries in professional baseball populations.
Article
Background Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results. Purpose/Hypothesis The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)–confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location. Study Design Cohort study; Level of evidence, 3. Methods All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist. Results Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping ( P = .499). Conclusion No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.
Article
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Background: Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads. Purpose:To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction. Study Design: Systematic review. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (“ulnar collateral ligament” OR “medial ulnar collateral ligament”) AND (“internal brace” OR “augmentation” OR “suture tape”). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases. Results: After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], –0.34 N·m; 95% CI, –1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, –1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, –0.53; 95% CI, –1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008). Conclusion: MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.
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Background It has previously been speculated that baseball pitchers who display excessive forearm pronation at foot contact (FC) have a higher propensity toward ulnar collateral ligament injury and subsequent surgery. Purpose To evaluate the association between degree of forearm pronation/supination at FC and throwing arm kinetics in high school and professional pitchers, at both the individual (intrapitcher) and the group (interpitcher) level. Study Design Descriptive laboratory study. Methods High school (n = 41) and professional (n = 196) pitchers threw 8 to 12 fastballs while being assessed with a 3-dimensional motion-capture system (480 Hz). Pitchers at each playing level were divided into a supination or pronation subgroup depending on degree of forearm pronation at FC. Regression models were built to observe the relationship between forearm pronation at FC and kinetic and kinematic parameters of interest. Results At both the individual and the group level of high school and professional pitchers, there was no significant correlation between forearm pronation at FC and elbow varus torque ( P min = .21). For every 10° increase in forearm pronation at FC in the individual high school pitcher, elbow flexion at FC decreased by 5°, whereas maximum elbow extension velocity was achieved 0.6% later in the pitch. In addition, elbow medial force increased by 4.1 N and elbow varus torque increased by 0.8 N·m for every 10° increase in forearm supination at FC. For every 10° increase in forearm supination in the individual professional pitcher, ball velocity increased by 0.5 m/s, shoulder external rotation at FC decreased by 11°, and elbow medial force decreased by 5.5 N. Conclusion Supination- or pronation-predominant forearm motion during the pitch did not significantly differ between playing levels. Excessive forearm pronation at FC was not a significant risk factor for increased throwing arm kinetics for high school or professional pitchers. There was a weak positive association between forearm supination at FC and elbow varus torque in the individual high school pitcher. Ultimately, coaches and pitchers may be better served by redirecting their focus to other mechanical aspects of the pitch that may have stronger associations with injury risk implications as well as performance.
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Background: The ulnar collateral ligament (UCL) is a commonly injured elbow stabilizer during throwing. Shear wave elastography (SWE) is a technique that may reveal structural changes in the UCL that are indicative of ligament health and injury risk. The purpose of this study was to assess preseason and inseason shear wave velocity (SWV) in the UCL of collegiate pitchers and to asses repeatability of this measurement technique in healthy volunteers. Methods: Seventeen collegiate baseball pitchers and 11 sex-matched volunteers were recruited. Two-dimensional SWE of the UCL was performed by a single radiologist. In pitchers, SWV was measured at the proximal, midsubstance, and distal UCL for dominant and nondominant elbows preseason, midseason, and postseason, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire scores were recorded. In volunteers, SWV was measured at UCL midsubstance in dominant elbows at 3 separate occasions over 1 week. An independent samples t-test was used to compare preseason midsubstance measures between pitchers and the healthy volunteers. A mixed-model analysis of covariance (covaried on preseason measures) was used to compare SWV measures at the preseason, midseason, and postseason time points. A similar generalized linear model for nonparametric data was used to compare KJOC scores. Type-I error was set at P < .05. Results: Mean preseason midsubstance dominant arm UCL SWV did not significantly differ between the pitchers (5.40 ± 1.65 m/s) compared to the healthy volunteers (4.35 ± 1.45 m/s). For inseason measures among the pitchers, a decrease in midsubstance (-1.17 ± 0.99 m/s, P = .021) and proximal (-1.55 ± 0.91 m/s, P = .001) SWV was observed at midseason compared to preseason. The proximal measure was also observed to be significantly lower than the nondominant arm (-1.97 ± 0.95 m/s, P < .001). Proximal SWV remained reduced relative to the preseason and the postseason mark (-1.13 ± 0.91 m/s, P = .015). KJOC scores decreased at midseason compared to preseason (P = .003) but then increased to a similar preseason value at the postseason measurement (preseason = 92 ± 3, midseason = 87 ± 3, postseason = 91 ± 3). The repeatability coefficient of SWE in the volunteer cohort was 1.98 m/s. Conclusion: Decreased SWV in the proximal and midsubstance of the dominant arm UCL at midseason suggests structural changes indicative of increasing laxity or 'softening' of the UCL. Associated decline in KJOC scores suggests that these changes are associated with functional decline. Future studies with more frequent sampling would be invaluable to further explore this observation and its significance for predicting and managing UCL injury risk.
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Background: Pitching performance metrics, durability, and reinjury after Tommy John surgery in professional baseball players have not been well described. Purpose: The purpose of this study was to determine the likelihood of return to professional competition, reinjury rate, and change in performance after Tommy John surgery in Major League Baseball pitchers. The hypothesis was that performance metrics and durability will decline after surgery. Study design: Cohort study; Level of evidence, 3. Methods: Publicly available records were accessed to generate a list of all Major League Baseball pitchers from 1999 to 2011 who had undergone ulnar collateral ligament reconstruction at any point in their careers; those with multiple reconstructive procedures were excluded. Return to active (≥1 game) or established (≥10 games) competition and/or placement on the disabled list was documented for each player. Among established players, pitching performance was compared pre- and postoperatively, as well as with age-matched control pitchers. Results: Of 147 pitchers included, 80% returned to pitch in at least 1 Major League Baseball game. Only 67% of established pitchers returned to the same level of competition postoperatively, and 57% of established players returned to the disabled list because of injuries to the throwing arm. Finally, performance declined across several metrics after surgery compared with preinjury levels, such as earned run average, batting average against, walks plus hits per inning pitched, percentage of pitches thrown in the strike zone, innings pitched, percentage fastballs thrown, and average fastball velocity (P < .05 for all). However, these declines were not statistically different from similar declines found in age-matched controls who did not undergo Tommy John surgery. Conclusion: Return to the disabled list after Tommy John surgery is common among professional pitchers (>50%), and performance declines across several major metrics after surgery. Patients undergoing Tommy John surgery should be counseled appropriately regarding the likelihood of return to preinjury levels of competition and performance.
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Background Ulnar collateral ligament (UCL) reconstructions are relatively common among professional pitchers in Major League Baseball (MLB). To the authors’ knowledge, there has not been a study specifically analyzing pitching velocity after UCL surgery. These measurements were examined in a cohort of MLB pitchers before and after UCL reconstruction. Hypothesis There is no significant loss in pitch velocity after UCL reconstruction in MLB pitchers. Study Design Cohort study; Level of evidence, 3. Methods Between the years 2008 to 2010, a total of 41 MLB pitchers were identified as players who underwent UCL reconstruction. Inclusion criteria for this study consisted of a minimum of 1 year of preinjury and 2 years of postinjury pitch velocity data. After implementing exclusion criteria, performance data were analyzed from 28 of the 41 pitchers over a minimum of 4 MLB seasons for each player. A pair-matched control group of pitchers who did not have a known UCL injury were analyzed for comparison. Results Of the initial 41 players, 3 were excluded for revision UCL reconstruction. Eight of the 38 players who underwent primary UCL reconstruction did not return to pitching at the major league level, and 2 players who met the exclusion criteria were omitted, leaving data on 28 players available for final velocity analysis. The mean percentage change in the velocity of pitches thrown by players who underwent UCL reconstruction was not significantly different compared with that of players in the control group. The mean innings pitched was statistically different only for the year of injury and the first postinjury year. There were also no statistically significant differences between the 2 groups with regard to commonly used statistical performance measurements, including earned run average, batting average against, walks per 9 innings, strikeouts per 9 innings, and walks plus hits per inning pitched. Conclusion There were no significant differences in pitch velocity and common performance measurements between players who returned to MLB after UCL reconstruction and pair-matched controls.
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Background Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball (MLB) pitchers in the United States. Purpose To determine (1) the rate of return to pitching (RTP) in the MLB after UCL reconstruction, (2) the RTP rate in either the MLB and minor league combined, (3) performance after RTP, and (4) the difference in the RTP rate and performance between pitchers who underwent UCL reconstruction and matched controls without UCL injuries. Study Design Cohort study; Level of evidence, 3. Methods Major League Baseball pitchers with symptomatic medial UCL deficiency who underwent UCL reconstruction were evaluated. All player, elbow, and surgical demographic data were analyzed. Controls matched by age, body mass index, position, handedness, and MLB experience and performance were selected from the MLB during the same years as those undergoing UCL reconstruction. An “index year” was designated for controls, analogous to the UCL reconstruction year in cases. Return to pitching and performance measures in the MLB were compared between cases and controls. Student t tests were performed for analysis of within-group and between-group variables, respectively. Results A total of 179 pitchers with UCL tears who underwent reconstruction met the inclusion criteria and were analyzed. Of these, 148 pitchers (83%) were able to RTP in the MLB, and 174 pitchers were able to RTP in the MLB and minor league combined (97.2%), while only 5 pitchers (2.8%) were never able to RTP in either the MLB or minor league. Pitchers returned to the MLB at a mean 20.5 ± 9.72 months after UCL reconstruction. The length of career in the MLB after UCL reconstruction was 3.9 ± 2.84 years, although 56 of these patients were still currently actively pitching in the MLB at the start of the 2013 season. The revision rate was 3.9%. In the year before UCL reconstruction, pitching performance declined significantly in the cases versus controls in the number of innings pitched, games played, and wins and the winning percentage ( P < .05). After surgery, pitchers showed significantly improved performance versus before surgery (fewer losses, a lower losing percentage, lower earned run average [ERA], threw fewer walks, and allowed fewer hits, runs, and home runs) ( P < .05). Comparisons between cases and controls for the time frame after UCL reconstruction (cases) or the index year (controls) demonstrated that cases had significantly ( P < .05) fewer losses per season and a lower losing percentage. In addition, cases had a significantly lower ERA and allowed fewer walks and hits per inning pitched. Conclusion There is a high rate of RTP in professional baseball after UCL reconstruction. Performance declined before surgery and improved after surgery. When compared with demographic-matched controls, patients who underwent UCL reconstruction had better results in multiple performance measures. Reconstruction of the UCL allows for a predictable and successful return to the MLB.
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Although baseball is a relatively safe sport, numerous reports suggest a rapid rise in elbow injury rate among youth baseball pitchers. PUBMED WAS SEARCHED FOR EPIDEMIOLOGIC, BIOMECHANICAL, AND CLINICAL STUDIES OF ELBOW INJURIES IN BASEBALL (KEYWORDS: "youth OR adolescent" AND baseball AND pitching AND "ulnar collateral ligament OR elbow"; published January 2000 - April 2012). Studies with relevance to youth baseball pitchers were reviewed. Relevant references from these articles were also retrieved and reviewed. Original data, insight, and recommendations were added. The majority of baseball elbow injuries are noncontact injuries to the dominant arm resulting from repetitive pitching. Five percent of youth pitchers suffer a serious elbow or shoulder injury (requiring surgery or retirement from baseball) within 10 years. The risk factor with the strongest correlation to injury is amount of pitching. Specifically, increased pitches per game, innings pitched per season, and months pitched per year are all associated with increased risk of elbow injury. Pitching while fatigued and pitching for concurrent teams are also associated with increased risk. Pitchers who also play catcher have an increased injury risk, perhaps due to the quantity of throws playing catcher adds to the athlete's arm. Another risk factor is poor pitching biomechanics. Improper biomechanics may increase the torque and force produced about the elbow during each pitch. Although throwing breaking pitches at a young age has been suggested as a risk factor, existing clinical, epidemiologic, and biomechanical data do not support this claim. Some elbow injuries to youth baseball pitchers can be prevented with safety rules, recommendations, education, and common sense. Scientific and medical organizations have published safety rules and recommendations, with emphasis on prevention of overuse and pitching while fatigued. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT): A.
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Baseball pitching kinematics, kinetics, ball velocity, and injuries at the shoulder and elbow are related. PubMed and Sport Discus were searched for original studies published between 1994 and 2008. Relevant references in these studies were retrieved. Inferential studies that tested relationships between kinematics and kinetics were included, as were studies that tested relationships between kinematics and ball velocity. Descriptive studies that simply quantified kinematics and/or kinetics were excluded. SEVERAL KINEMATIC PARAMETERS AT THE INSTANT OF FOOT CONTACT WERE ASSOCIATED WITH INCREASED UPPER EXTREMITY KINETICS: front foot position, front foot orientation, shoulder abduction, and shoulder horizontal adduction. The timing of shoulder external rotation, pelvis rotation, and upper trunk rotation was associated with increased kinetics and decreased ball velocity. Low braking force of the lead leg and a short stride were associated with decreased ball velocity. Decreased maximum shoulder external rotation, shoulder abduction, knee extension, and trunk tilt were also associated with decreased ball velocity. As pitchers develop, kinematic values remain similar, their variability reduces, and kinetic values gradually increase. Slight kinematic variations were seen among pitch types, although the kinetics of fastballs and curveballs were relatively the same; changeup kinetics were the lowest. As pitchers fatigued, kinetic values remained constant, but increases in arm pain were reported. Several kinematic parameters were related to joint kinetics and ball velocity. To enhance performance and reduce injury risk, pitchers need to learn proper fastball mechanics at an early age. A changeup is recommended as a safe secondary pitch to complement the fastball; the curveball can be added after fastball and changeup mechanics are mastered. Avoiding overuse and pitching while fatigued is necessary to minimize the risk of arm injury.
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There are several large series of outcomes after ulnar collateral ligament (UCL) reconstruction that have 1 or 2 javelin throwers included. To our knowledge, however, there are no reports that focus solely on the results of UCL reconstruction in this group of athletes. HYPOTHESIS/PURPOSE: We hypothesize that by using modern UCL reconstruction techniques, javelin throwers can reliably expect to return to their sport. Additionally, we review the principles behind postoperative rehabilitation in these athletes, as it differs from the usual approach used with baseball players. Case series; Level of evidence, 4. This was a retrospective review of 10 javelin throwers who underwent UCL reconstruction between 2006 and 2009 using the docking technique. There were 5 college and 5 high school javelin throwers. The average age was 18.5 years (range, 18-21 years). All patients, before being indicated for ligament reconstruction, failed a course of nonoperative management that included rest, physical therapy, and a structured attempt to return to throwing. Postoperatively, patients were evaluated using the Conway Scale and the Andrews-Timmerman Score. Patients were evaluated at a minimum 2-year follow-up. The average follow-up was 28.9 months after surgery (range, 24-45 months). On the Conway Scale, 9 of the 10 players had excellent outcomes (90%). There was one fair (10%) outcome. Average time to return to previous level of competition was 15 months. The mean Andrews-Timmerman Score was 97 (range, 85-100). Overall, 100% (10/10) of the patients were subjectively satisfied with their clinical outcome. Similar to other overhand athletes with UCL insufficiency, javelin throwers can reliably expect to return to their previous level of play after surgical reconstruction. A thorough understanding of the unique demands placed on these athletes because of the different throwing motion is helpful when tailoring their postoperative rehabilitation protocol. Additionally, these athletes must be counseled that the postoperative course is associated with an extended period of time until return to previous level of competition when compared with baseball players.
Article
Reconstruction of the elbow ulnar collateral ligament, known as Tommy John surgery, is being performed with increasing frequency. We hypothesized that the public's perception of Tommy John surgery may be incorrect with regard to the indications, operative technique, risks, recovery time, and benefits obtained from the procedure. A questionnaire was developed to measure an individual's perception of Tommy John surgery with regard to indications, operative technique, risks, recovery time, and overall benefits of the procedure. Questionnaires were given via a one-on-one interview or mailing after receiving prior consent. Questionnaires were completed by 189 players, 15 coaches, and 31 parents. Data were calculated and statistical analysis was performed. Indications: Thirty percent of coaches, 37% of parents, 51% of high school athletes, and 26% of collegiate athletes believed that Tommy John surgery should be performed on players without elbow injury to enhance performance. Risk Factors: Thirty-one percent of coaches, 28% of players, and 25% of parents did not believe number of pitches thrown to be a risk factor, and 38% of coaches, 29% of players, and 25% of parents did not relate pitch type (eg, curve balls) with risk of injury. Benefits: Many players (28%) and coaches (20%) believed that performance would be enhanced beyond pre-injury level. Return to Play: Individuals underestimated the time required to return to competition. Twenty-four percent of players, 20% of coaches, and 44% of parents believed that return would occur in < 9 months. This study is the first of its kind to investigate public perception of Tommy John surgery and has identified an alarming percent of players, coaches, and parents with misperceptions. Efforts should be made in our communities to better educate players, coaches, and parents regarding elbow ulnar collateral ligament injury in youth baseball players.
Article
Isolated ulnar collateral ligament (UCL) injury from repetitive throwing was first described by Waris in 1946 in javelin throwers1. Although these injuries were once considered career-ending for athletes, a surgical technique pioneered by Jobe in 1974 facilitated successful return to competition2. Since that time, modifications of the original procedure have resulted in improved clinical results. The present article provides a comprehensive review of current concepts related to UCL injury in throwing athletes, including a review of relevant anatomy and biomechanics, the mechanism of UCL injury and associated elbow pathology, and the evolution of UCL reconstruction procedures and clinical outcomes. The UCL is composed of three bundles: anterior, posterior, and oblique; the oblique bundle is commonly termed the transverse ligament3,4 (Fig. 1). Gross anatomical studies have demonstrated that the anterior bundle is easily distinguished from the underlying joint capsule5,6. The anterior bundle consists of two separate histological layers: the deeper layer is composed of collagen bundles contained within the capsule, and the shallower layer is a distinct ligamentous structure superficial to the capsule7. The anterior bundle originates from the anteroinferior edge of the medial humeral epicondyle and inserts onto the sublime tubercle of the ulna. There is a distinct ridge on the sublime tubercle that divides the anterior bundle into two equally sized bands, the anterior and posterior bands5,6 (Fig. 2). The area of the origin of the anterior bundle on the medial humeral epicondyle is 45.5 ± 9.3 mm2, whereas the insertion on the sublime tubercle is much broader, measuring 127 ± 35.7 mm2 (Fig. 3)6. Fig. 1 Anatomy of the ulnar collateral ligament. (Reproduced from: Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in …
Article
Elbow ulnar collateral ligament (UCL) reconstruction has become the standard of care for the throwing athlete with a symptomatic ruptured or insufficient ligament and the desire to resume competitive play. Since Jobe's initial description of UCL reconstruction, the technique has evolved. A novel modification was the "docking" technique developed by Altchek. Subsequently, the docking technique as originally described was slightly modified. Arthroscopy is no longer routinely performed, and in some cases, a 3-strand graft is used. We treated 21 overhand athletes with clinical and radiographic evidence of UCL insufficiency with ligament reconstruction using a modified version of the docking technique using a 3-strand graft. There were 5 professional, 11 college, and 5 high school baseball players in the reconstructed group. Athletes were evaluated postoperatively by use of the Conway Scale. Of the 21 patients who underwent the modified docking technique with a three-strand graft, 19 (90%) had excellent results. There were 2 good results and no complications. UCL reconstruction can successfully treat athletes with UCL insufficiency. Several different reconstruction techniques have been described. By use of the docking and modified docking techniques, good to excellent results can be achieved in the majority of cases with a low complication rate.
Article
Little is known about the injury rates in Major League Baseball (MLB) players, as a formal injury surveillance system does not exist. The goal of this study was to characterize the epidemiology of MLB injuries over a 7-year period. Injuries in MLB would be common. Descriptive epidemiologic study. The authors analyzed the MLB disabled list data from 2002 through 2008. Injuries were analyzed for differences between seasons, as well as during seasons on a monthly basis. The injuries were categorized by major anatomic zones and then further stratified based on injury type. Position-specific subanalyses for pitcher and position players were performed. From the 2002 season through the 2008 season, an average of 438.9 players per year were placed on the disabled list, for a rate of 3.61 per 1000 athlete-exposures. There was a significant 37% increase in injuries between 2005 and 2008. The highest injury rate during the season was during the month of April (5.73/1000 exposures) and the lowest in September (0.54/1000 exposures). No differences were noted in the injury rates between the National League and the American League (incidence rate ratio [IRR] = 1.06; 95% confidence interval [CI] = 0.98, 1.15). Pitchers experienced 34% higher incidence rates for injury compared with fielders during the study period (IRR = 1.34; 95% CI = 1.25, 1.44). Among all player injuries, upper extremity injuries accounted for 51.4% while lower extremity injuries accounted for 30.6%. Injuries to the spine and core musculature accounted for 11.7% while other injuries and illnesses were 6.3% of the total disabled list entries. There was a significant association between position played and anatomic region injured (P < .001), with pitchers experiencing a significantly greater proportion of injuries to the upper extremity (67.0%; 95% CI = 63.1%, 70.9%) compared with fielders (32.1%; 95% CI = 29.1%, 35.1%). Conversely, fielders experienced a significantly greater proportion of injuries to the lower extremity (47.5%; 95% CI = 43.8%, 51.1%) compared with pitchers (16.9%; 95% CI = 14.9%, 18.8%). The mean number of days on the disabled list was 56.6. Overall, a greater proportion of disability days were experienced by pitchers (62.4%; 95% CI = 62.0%, 62.8%; P < .001) compared with fielders (37.6%; 95% CI = 37.3%, 37.9%). Injuries in MLB resulting in disabled list designation are common. Upper extremity injuries were predominant in pitchers, while lower extremity injuries are more common in position players. These data may be used in the development of a formal MLB injury database, as well as in the development and implementation of specific preseason training and in-season conditioning for injury prevention.