Risk Factors Leading to UCL Reconstruction and Revision Surgery

Transcription

Skyline - The Big Sky Undergraduate Journal
Volume 2 | Issue 1
Article 2
2014
Risk Factors Leading to UCL Reconstruction and
Revision Surgery: A Case Report of a Division I
Collegiate Pitcher
Taylor M. Bennett
Northern Arizona University, [email protected]
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Recommended Citation
Bennett, Taylor M. (2014) "Risk Factors Leading to UCL Reconstruction and Revision Surgery: A Case Report of a Division I
Collegiate Pitcher," Skyline - The Big Sky Undergraduate Journal: Vol. 2: Iss. 1, Article 2.
Available at: http://skyline.bigskyconf.com/journal/vol2/iss1/2
This Research Article is brought to you for free and open access by Skyline - The Big Sky Undergraduate Journal. It has been accepted for inclusion in
Skyline - The Big Sky Undergraduate Journal by an authorized administrator of Skyline - The Big Sky Undergraduate Journal.
Risk Factors Leading to UCL Reconstruction and Revision Surgery: A
Case Report of a Division I Collegiate Pitcher
Keywords
UCL, Elbow Injury, Throwing Injury, Baseball, Tommy John, Tommy John Surgery, Reconstruction, Elbow
Surgery, Risk Factors
This research article is available in Skyline - The Big Sky Undergraduate Journal: http://skyline.bigskyconf.com/journal/vol2/iss1/2
Bennett: Risk Factors Leading to UCL Reconstruction and Revision: A Case Report
Introduction
The ulnar collateral ligament (UCL) of the elbow is the principal
stabilizing structure that acts to oppose valgus stress on the elbow.1-5Injury to the
UCL is a result of valgus overload seen almost exclusively in overhead throwing
sports such as baseball, softball, football, tennis and javelin.5 Chronic dysfunction
and acute rupture of the UCL is attributed to tensile overload resulting in microtrauma and repetitive joint attenuation.5 Pain, tightness, and instability are most
notable between the late cocking phase and early acceleration phase of the
throwing motion.4
In a study by Cain et al. 98% of patients who underwent UCL
reconstruction (UCLR) were male; 95% participated in baseball, 32% played
professionally, 48% played collegiately, and the remaining 20% played at the high
school or recreational level.8 Of these baseball players 90% were pitchers and the
average patient was 21.5 years of age.8 This report will be focused primarily on the
baseball pitcher, due to the large influence of the baseball population and its
pitchers.
A growing trend in the number of UCLR procedures has been observed.
Cain et al. also noted a significant increase in the number of procedures done in
their clinic; nearly 500 from 1999-2002 to nearly 800 between the years of 20032006.8 Similarly, Petty et al. reported an increase in UCLR procedures performed;
85 from 1988-1994 to 609 from 1995-2003 with a 50% increase among high
school baseball players.9
A possible complication with any procedure that utilizes a tendon graft is
graft failure. Graft failure following UCLR has only been reported in 1% of
cases.10As the number of primary reconstructions increases the number of revision
reconstructions increases. Jones et al. observed that 18 MLB pitchers underwent
UCLR revision over a 14 year period with 14 of those procedures occurring over
the second half of the time period.10 This trend and the factors involved in graft
failure and the need for a revision UCLR will be analyzed for an individual case
involving a division I baseball player. The main objective is to highlight the
contributing factors that led to this individual case so that those who assess,
rehabilitate, and seek to prevent UCL injuries in baseball players across all levels
of competition can identify them.
Functional Anatomy
The UCL is a triangular ligamentous complex located at the medial elbow
and is comprised of three bundles: the transverse, posterior oblique, and the
anterior oblique bundles.5, 11 Figure 1 (Appendix A) illustrates the UCL complex.
The anterior oblique bundle originates at the medial epicondyle of the humerus
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Skyline - The Big Sky Undergraduate Journal, Vol. 2 [2014], Iss. 1, Art. 2
and inserts on the medial aspect of the coranoid process of the ulna.5, 11 The anterior
bundle serves as the chief valgus restraint from 20°-120° of elbow flexion. 5 The
transverse bundle originates from the medial olecranon process of the ulna and
inserts onto the infero-medial portion of the coranoid process of the ulna. 5, 11 The
transverse bundle plays no role in the resistance of valgus forces about the elbow.
Lastly, the posterior oblique bundle is a fan shaped extension of the joint capsule
that runs vertically from the medial epicondyle to its insertion on the medial
border of the trochlear notch of the ulna.5 The posterior oblique bundle resists
valgus stress at 90° of elbow flexion.5
The forearm musculature is also important as it plays an integral role in the
dynamic stabilization of the humero-ulnar joint. The forearm musculature also
controls positioning of the hand and forearm during the throwing motion. In
addition, the flexor-pronator mass acts to counteract valgus force on the UCL by
providing an opposing varus force.12The flexor-pronator mass and its components
that support the medial elbow and UCL will only be reviewed. These muscles are
the pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and
the flexor digitorum superficialis. The common point of origin at the medial
epicondyle of the humerus allows the flexor-pronator mass to counteract valgus
force.
Biomechanics
The overhead throwing motion (Appendix A, Figure 2) can be described as
a transfer of kinetic energy from the lower extremity through the trunk to the
shoulder and elbow and finally to the hand as a result of linear and angular
velocity, acceleration, and torque.13, 15 The six phases of the throwing motion are
the wind-up, stride, arm cocking, acceleration and deceleration phases, ending
with the follow-through. 13 UCL torque and activation is at its highest during the
early cocking phase through the acceleration phase and reaches peak varus torque
and valgus stress between the late cocking and early acceleration phases.13, 14
The average valgus stress generated by a pitch from an adult overhead
throwing athlete is 64 N.m.12 This force is equivalent to the weight of 150
baseballs.12The anterior band of the UCL provides approximately half of the varus
counter-torque when the elbow is flexed to 90° and provides even greater restraint
when flexed greater than 90°. 12 On average, each pitch thrown approaches the
tensile threshold of the UCL which is approximately 33 N.m. 12, 13 In elite throwers
total elbow valgus torque has been recorded at 120 N.m.13 Tensile overload of the
UCL is the primary cause of acute rupture and chronic ligament attenuation.10
Tensile overload occurs when valgus stress is greater than the varus counter-torque
provided by the dynamic stabilizers of the elbow. These stabilizers include the
UCL, flexor-pronator mass, triceps, and glenohumeral (GH) internal rotation (IR)
http://skyline.bigskyconf.com/journal/vol2/iss1/2
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of the shoulder.12 Recent studies have shown that a combination of shoulder IR and
pronation of the forearm during deceleration and follow-through achieves varus
acceleration resulting in valgus unloading of the UCL.12, 13, 16
Diagnosis
Diagnosis of acute UCL rupture or chronic ligament attenuation should be
executed as a multifaceted approach comprised of a thorough history, physical
examination and imaging studies. Cain et al. reported that 53% of subjects were
classified under the chronic UCL injury category while 47% were categorized as
having sustained acute UCL trauma. Seventy-three percent of these patients
reported that onset of symptoms occurred while participating in a game.8
The most common symptom reported by throwers with UCL injury is pain
between the late cocking and early acceleration phase of the throwing motion.1, 4, 5, 6,
8, 17
Many throwers who exhibit chronic pain and instability also report a decrease in
velocity and a subsequent loss of control when throwing.5, 17 Individuals who have
had an acute rupture often times report a popping sensation, followed by sharp
pain in the medial elbow after an individual throw and cannot continue throwing.5,
17
Numbness and tingling in the forearm and 4th and 5th digits are also frequently
reported after acute UCL rupture due to ulnar nerve compression.17
The history portion of the exam should document the patient’s dominant
hand, throwing style, accuracy, workload, and occurrence of symptoms.5 If the
injured party is a pitcher the examiner should also obtain information regarding
pitch type, workload, and pitches that reproduce symptoms.5 Conversely,
individuals who are found to have chronic valgus instability and potential UCL
injury will present with symptoms of medial elbow pain, soreness, and tightness
while throwing for an extended time-frame.1-8 These symptoms are often managed
with conservative treatment. Overuse is the number one factor associated with
UCL injury. 9 Those with chronic instability who do not respond favorably to
conservative treatment will present with symptoms that continue to worsen as
activity continues.4, 9
The findings of the physical examination of the UCL are obtained through
a series of structural tests that compare the pain and laxity experienced in the
injured elbow to the non-injured elbow. When acute rupture or chronic attenuation
is present the examiner will note point tenderness approximately 2 cm distal to the
medial epicondyle.5, 6 Also, joint gapping can be felt in some cases of complete
rupture when valgus force is applied to the elbow. It is also important during
physical examination to assess the ROM and function of the shoulder and scapula.
3, 5, 14, 19, 20
An injury or imbalance of these structures can cause or predispose the
3, 5, 14, 19, 20
Identification of the palmaris longus
patient to further UCL damage.
3
tendon is critical to report to the surgeon as it is the most frequently used graft
during UCLR.6
Structural evaluation of the UCL complex is done by performing multiple
special tests in combination with imaging studies.4-6 These tests are the valgus
stress test, modified milking maneuver, and moving valgus test (Appendix,
Figures 3-5). These tests aim to recreate the reported symptoms of pain and
instability. Joint laxity is considered a secondary marker as it has proved
inconsistent due the minimal amount of gapping that occurs at the humero-ulnar
joint.9 Detection of valgus instability through physical examination is often
difficult to quantify as many throwers have increased valgus laxity of the nondominant arm as well.5, 18
Evaluation of the shoulder for glenohumeral internal rotation deficit
(GIRD), dyskinesis of the scapula, and rotator cuff strength are an integral part of
assessment of determining the condition of the throwing elbow.18 Assessment of
core stability and strength as well as hip rotation values is necessary as
dysfunction from any of these categories have been shown to affect the health and
stability of the throwing elbow.14 Fifty to ninety-four percent of patients across
multiple studies that have sustained an elbow injury have exhibited problems with
the scapula, rotator cuff, core stability and strength, as well as hip rotation.5, 15, 16, 18, 19,
20
Imaging Studies
Chronic UCL injury can be noted through radiographs due to the presence
of loose bodies, ossification of the ligament, as well as osteophytes around the
olecranon process.22 An associated trend between ossification of the UCL and
partial and full thickness tears has been noted.23Valgus stress radiographs may be
used to assess medial joint line gapping.22, 24Azar et al. reported that 46% of their
athletes who had UCLR had positive preoperative valgus stress radiographs.26
Thompson et al. reported that 88% of their athletes prior to UCLR presented with
joint opening to valgus stress that was 2mm greater than the uninjured elbow.27
MRI has been reported as 57% to 79% sensitive and 100% specific for
UCL tears.28 UCL injury may present on a MRI as laxity, irregularity, reduced
definition, and increased signal within and around the ligament as a result of
edema. Contrast MRI or MR arthrography with intra-articular gadolinium has been
reported to have 97% sensitivity and 100% specificity for UCL tears. Due to its
diagnostic accuracy the MR arthrogram with contrast has become the gold
standard diagnostic tool for identifying acute and undersurface UCL tears after
plain radiographs are obtained.5, 18, 22 In cases of chronic UCL injury MR
4
arthrography is much less effective because dye leakage that is seen in acute
ligament tear is often not present.5 (Appendix A, Figures 3 & 4)
A study by Dodson et al. established 3 criteria for selecting athletes with
UCL injury for surgery: (1) Positive MRI or MR arthrogram that suggests UCL
injury; (2) A history of medial elbow pain in proximity to the UCL that occurs
during the late cocking phase through the acceleration phase of the throwing
motion; and (3) pain that is severe enough that it prevents the athlete from
participating in competition.1
Reconstruction Techniques
The first UCLR utilized a free tendon autograft configured in a figure-of-8
pattern and anchored in bone tunnels located at the medial epicondyle and
coronoid process.6, 24 At that time the UCLR was considered a revolutionary
procedure that allowed throwers to return from a career ending injury. The first
study published by Jobe et al. reviewed UCLR in 16 cases and reported a 63% rate
of return to pre-injury level. Numerous modifications to the original UCLR
procedure have since been implemented, including the modified Jobe technique,
the docking technique, the modified docking technique, and interference screw
fixation (Appendix A, figures 5-7).6 These modifications have resulted in improved
patient outcomes with some studies reporting a 90% return to play (RTP) rate.1, 6, 8,
Watson et al. conducted the largest review of UCLR techniques to date
which was comprised of 1368 patients across 21 studies (Appendix B, table 1).6
Seventy-eight percent of the patients in this study were collegiate or professional
athletes.6 This study analyzed the number of patients per technique, graft used,
post-operative complication rates, and RTP statistics.
The technique with the highest patient number was the modified Jobe
technique at 78% (1064/1368). 6 Complication rate was 19% across all studies, with
the Jobe technique (30%) and the modified Jobe technique (19%) exhibiting
significantly larger complication rates than the other techniques (Appendix B,
Table 2).6 Graft failure with subsequent revision surgery occurred in only 1% of all
1368 patients. The technique associated with the largest number of revision
surgeries was the modified Jobe technique with nine.6 Fifty-five percent of patients
had an ipsilateral palmaris longus autograft, while 24% had a gracilis autograft and
11% of patients had a contralateral palmaris longus autograft.6 Other grafts,
primarily the gracilis autograft, may be utilized in the rare instance when the
palmaris longus is not present in the patient.
5
The overall RTP rate was reported at 79%. 6 Interference screw fixation,
modified docking, and docking techniques reported RTP rates above or equal to
90%. The modified Jobe technique reported a RTP rate of 78%. Another large
review reported that the average RTP time in 743 was 11.6 months (Appendix B,
Table 3).8
Revision Reconstruction
Multiple studies have noted that approximately 1% of all UCLR
procedures result in the need for revision.3, 8, 10 Jones et al observed that 18 MLB
pitchers underwent UCLR revision over a 14 year period with 14 of those
procedures occurring over the second half of the time period.10 The cases of 15
3
pitchers who underwent UCLR revision were reviewed by Dines et al. The same
authors reported a significant decrease in RTP rate (33%) in comparison to the
RTP rate of pitchers who underwent an initial UCLR (79%) and a complication
rate of 40%, twice that of the norm.3, 10 After returning to competition the tolerable
workload of relief pitchers was half that of their pre-injury level and one third in
starting pitchers.3, 10 The decrease in workload is more than likely attributed to
continuation of post-surgical complications including ulnar nerve neuritis and
flexor-pronator mass tightness and pain. A scarcity of literature to dictate
rehabilitation and treatment of these individuals exists, which results in
speculation. 10
Rehabilitation
Conservative or non-operative rehabilitation for the throwing athlete has
become a highly debatable topic. Due to the high success rate of UCLR many
physicians choose to forego conservative rehabilitation as it has shown poor
results based on the RTP rates of throwing athletes.1, 5, 12 Success of non-operative
treatment has been documented to be 42% to 50% effective in returning throwing
athletes back to pre-injury participation levels.5, 12 This method of treatment is
almost exclusively implemented for athletes exhibiting chronic UCL attenuation.
Conservative treatment focuses on reduction of symptoms through varying
modalities first, followed by restoration of strength and pain free ROM of the
shoulder, elbow, forearm and wrist.12 A progression through sport specific
movements is then initiated. The initial restoration portion of treatment lasts
approximately 3 months followed by an interval throwing program that lasts for 2
months.12
The initial phase of rehabilitation (Phase I) lasts for 3 weeks and begins
directly after surgery.1, 5, 8 It is critical to restore full elbow ROM which should be
accomplished by week 6.5, 8 During the second phase (weeks 4-10), a progressive
6
isotonic strengthening program focusing on the scapular stabilizers, rotator cuff,
and surrounding arm musculature is started. Shoulder ROM exercises and the
thrower’s ten exercise protocol should be initiated during phase II.5 During the
third phase (weeks 10-16) advanced strengthening and sport and position specific
rehabilitation exercises should begin. Restoration of shoulder internal and external
rotation is paramount to allow the throwing athlete to successfully progress to and
through advanced sport and position specific movement exercises.1, 5, 8 At the 12th
week, the athlete can start an isotonic lifting program which includes bench press,
seated rowing, lat pull downs, triceps push downs, and biceps curls, while
continuing to perform exercises that accentuate sport-specific movements.1, 5, 8 The
throwing athlete begins a 2-handed plyometric throwing series at 12 weeks, and a
1-handed plyometric throwing program at the start of the 14th week. Total body
conditioning, core stability and lower extremity strengthening exercises should be
emphasized throughout phase III. Starting at week 16 (Phase IV), an interval
throwing program is initiated.5, 8, 17 The timeline through the throwing program for
position players is abbreviated as pitchers have higher physical demands and throw
volume. The throwing progression should be performed 3-4 times weekly up to 10
months after surgery.8 At the 8 month mark the pitcher should then begin light
throwing off the mound.8, 17 The pitcher should ultimately progress to up and down
bullpens with variable rest between sets of pitches at the 10 month mark. After the
10th month the athlete should begin a gradual integration into team activities.
Athletic trainers, physical therapists, or doctors should make adjustments to this
progression as needed based on any physical findings and recurrence of symptoms.
Case Study
A 23 year old male who is a right-handed baseball pitcher at a division I
(DI) university underwent UCL reconstruction and UCLR revision within a 2 year
timeframe. The patient stated that he has been playing baseball for 19 years and
pitching since age 10. He has previous history of medial elbow pain that started at
age 10 and recurred intermittently from age 12 to 16. At age 16, an MRI was
performed to assess the structures of his throwing elbow with no positive findings
reported. At age 16, he began preventative maintenance of the shoulder and
forearm musculature.
The athlete’s high school pitching workload was approximately 8 starts per
season combined with intermittent throwing and bullpen sessions 2-3 times per
week. He did not participate in competition his 11th grade season due to persistent
medial elbow pain and diagnosed flexor-pronator mass tendinitis. His pitching
workload increased during his 12th grade season as he started 10 games. It is
notable that at the end of his 12th grade season he pitched 11 consecutive innings in
one day over the span of two games, throwing 174 total pitches. He lists his
pitches as a fastball, change-up, curveball, and slider. The athlete reported that his
7
highest recorded fastball velocity to date was approximately 93 mph. He began
throwing the curveball at age 12. He did not begin throwing the slider until age 16,
and did not begin throwing the change-up until he reached college at age 18.
At age 19 while warming up for his first collegiate starting appearance he
felt a pop followed by sharp, burning pain in his throwing elbow. His immediate
symptoms of localized pain and edema were managed and ROM restoration was
initiated prior to referral to the team physician. Non-contrast MRI was ordered by
the physician, who noted a partial thickness tear with calcification and thickening
of the UCL. Stress radiographs were ordered and returned a positive diagnosis of
2.5 mm medial elbow joint opening. The valgus stress test, modified milking
maneuver, and moving valgus stress test were each positive. Elbow and forearm
ranges of motion were within normal limits (WNL). Shoulder ROM was WNL
except for internal rotation, which produced values of 57° in the left shoulder
compared to 30° in the right shoulder. This deficit of 27° was noted and reported
as abnormal. The athlete was then referred to a surgeon who specialized in UCLR.
The athlete was scheduled for surgery in the summer of 2010, 1 month after the
initial injury. The athlete underwent UCL reconstruction using the modified Jobe
technique which was advised by his surgeon. This procedure utilized his left
gracilis tendon for the UCL graft as he was identified as palmaris longus deficient.
The surgeon confirmed thickening and degenerative changes to the anterior
oblique bundle, consistent with chronic injury. The patient began rehabilitation 10
days after UCLR. The patient noted zero complications from the procedure and
zero setbacks during the rehabilitative process. He completed the first 5 months of
the standardized UCL rehabilitation protocol outlined previously, meeting all
phase requirements and deadlines. Upon 3-month follow-up with the surgeon, the
athlete was reassessed. There were no positive structural tests or recreation of
previous symptoms. Strength and ROM were deemed as satisfactory. Upon 6month follow-up, the surgeon noted that the athlete’s progress was satisfactory for
his current stage of rehabilitation. He noted minimal tenderness proximal to the
medial epicondyle. All structural tests were negative and ROM and strength were
WNL. Upon 12-month follow-up, the patient reported that at month 11 he was
throwing and while attempting a throw of higher velocity felt notable pain and a
small pop in his right medial elbow. Prior to his follow up, the athlete’s symptoms
were treated with rest and NSAIDs. Upon physical assessment, ROM was WNL,
valgus laxity and the milking maneuver was negative. The positive moving valgus
test was noted as mildly positive as mild discomfort was recreated. The physician
ordered a MRI, and the report noted a focal signal over the UCL graft just distal to
the humeral tunnel, where a small partial tear was seen. The athlete was treated
conservatively and throwing was discontinued for 1 month to allow for resolution
of symptoms per the physicians orders. Once resolution of symptoms occurred the
athlete’s throwing program was reinitiated at the beginning of the phase in which
he reported symptoms. Care was taken to lengthen the last phases of the throwing
8
progression to allow for full restoration of throwing arm strength. The athlete was
cleared 14 months after initial UCLR and did not throw in an NCAA sanctioned
game until 20 months post-surgery.
Once cleared, the athlete continued the thrower’s ten program to maintain
proper upper extremity strength and stabilization. The athlete changed institutions
during this time and began pitching for another collegiate team. He pitched dually
as a starting and relief pitcher for 9 months (70 appearances) ranging from
between .2-8 innings. He pitched for his collegiate team and his summer travel
team during this time. The athlete stated that this number of appearances was the
highest work volume he had experienced in his baseball career.
Twenty-five months after UCLR, the athlete stated that he was throwing a
simulated game in the bullpen and felt a pop, followed by sharp pain, tingling in
his forearm and hand, as well as subsequent edema. He was referred to the
physician who performed his previous UCLR and a non-contrast MRI was ordered
followed by physical examination. The MRI reported a new, full thickness graft
rupture near the location of the previously mentioned partial tear. Examination of
the injured elbow reproduced symptoms with all three structural tests. Flexorpronator strength was WNL as was elbow ROM. The athlete opted to discontinue
baseball activities for 3 months adopting a regimen of rest from throwing and nonoperative rehabilitation. After three months, the athlete opted to undergo UCLR
revision. The same procedure as the initial UCLR was performed utilizing the
ipsilateral gracilis tendon graft. Post-operative rehabilitation was started 10 days
after surgery. Modifications were made to the rehabilitation timeline by
lengthening phases III & IV to allow for a more gradual progression. The athlete
was instructed not to throw until 5 months after surgery. Analysis of the athlete’s
pitching mechanics was done before the athlete transitioned to the pitching
progression. This was done to identify poor technique or improper biomechanics
present in the athlete’s delivery. His athletic trainer and pitching coach identified
three biomechanical adaptations during a pitching session. An open lead foot
position was seen upon front foot contact. In addition, when throwing the slider a
detectable change in the level of horizontal shoulder abduction was seen. Lastly, a
decrease in hip rotation and stride length was observed when the athlete became
fatigued. These poor mechanics were adjusted gradually throughout the pitching
progression. He noted a decrease in post-throwing arm tightness and soreness. The
athlete completed the pitching progression successfully without any issues and was
cleared by the team physician and his surgeon after 18 months of rehabilitation.
The team’s pitching coach and the athletic trainer placed him on a 45 pitch limit
during competition. He has since appeared in games and reports feeling near his
pre-injury status.
Discussion
9
The number one risk factor associated with UCL injury in overhead
throwers is overuse.1 Analysis of overuse in regard to its contribution in graft
failure in this individual case was noticeable. The review of the athlete’s case
highlighted multiple instances of excessive pitching and workload. This more than
likely contributed to the presence of medial elbow pain in the athlete starting at
age 10. This chronic valgus overload was seen and supported by the various
imaging studies performed as well as the initial reconstruction. The second
instance of prolonged overuse was seen upon return to pitching following initial
UCLR. The athlete pitched excessively and exceeded his pre-injury workloads
within a relatively short time after returning to play. Normally, pitchers who return
to play after UCL are put on an innings limit. This was not the case in this
particular instance. What should also be noted is the fact that rest through a
discontinuation of throwing was never reported. Petty et al. noted that pitchers
who discontinued throwing for a total of 2 months were much less likely to sustain
shoulder or elbow injuries as a result of throwing.9
The second noticeable abnormality upon review of the athlete’s case was
the degree of shoulder internal rotation deficit between the dominant and nondominant shoulders. Such deficit is often a result of the excessive amounts of
shoulder external rotation seen in overhead throwers as well as posterior joint
capsule tightening. Multiple studies have reported that pitchers with GH internal
rotation deficits were at greater risk for elbow injuries.16, 20This increased risk is
primarily because GH internal rotation acts to oppose valgus force on the elbow.
The risk factor increases as competition level rises due to the greater forces placed
on the upper extremity by elite throwers. GH internal rotation deficit should be
noted as a potential contributing factor for the need of the initial UCLR. This
association should also promote assessment of shoulder strength and ROM values
in cases of medial elbow pain and instability.
Poor pitching mechanics were present in the case of this athlete. Lead foot
opening upon ground contact, and decreased hip rotation and stride length were
observed during moments of reported fatigue. These biomechanical markers have
been noted in studies that analyzed similar mechanics in pitchers with UCL
injury.13-15The common association related to these markers is the amount of GH
horizontal abduction they create. These mechanical adaptations increase trunk
rotation resulting in the trailing of the arm behind the accelerating trunk and
torso.13 This puts increased valgus stress on the medial elbow and stresses the
anterior capsule of the shoulder and has been shown to predispose pitchers to
medial elbow and anterior shoulder injury.13-15 Once these mechanics were adjusted
to satisfactory patterns the athlete reported a decrease in forearm tightness and
soreness. One can hypothesize that this is a result of decreased valgus force on the
UCL and flexor-pronator mass. With the high volume and intensity involved in
10
competitive pitching small mechanical flaws can greatly magnify the tensile forces
placed on the UCL.
Analysis of the effects on the throwing arm as a result of pitch selection
has been conducted at length.14, 15 The fastball has been reported to produce the
greatest amount of varus torque.14 The varus torque created when throwing the
fastball at high velocities, 80 mph or greater, as well as the curveball and slider
approaches the tensile load of the UCL13-15 The slider has been reported as the only
pitch that has associated risk of valgus overload due to the combination of forearm
supination and GH horizontal abduction. These factors combined increase varus
torque on the UCL by an additional 10-15 N.m.14 The use of the slider at a young
age by the case subject combined with a notable increase in GH horizontal
abduction upon arm acceleration could have compounded the stress placed upon
the elbow resulting in the report of adolescent medial elbow pain progressing into
degenerative changes and ending with UCL rupture.
In conclusion, the risk factors associated with UCL injury are wide in
variety, thus further analysis should be done to establish a set of predictive factors
to better identify throwers who are at risk for injury or re-injury. Based on the
information provided through this case analysis it can be noted that the factors
associated with UCLR and revision in this individual case were cumulative in
nature. This accumulation of contributing factors resulted in chronic pain and
instability at a young age followed by UCL rupture. Overuse and dysfunctional
pitching mechanics were the primary risk factors identified to indicate the need of
the case subject’s revision procedure. If the growing trend of UCLR and UCLR
revision is to be altered pitching volume and frequency guidelines should be
established for adult throwers to reduce the risk for chronic overuse. Review of
shoulder function and ROM as well as throwing mechanics should be considered
in athletes who report medial elbow pain, instability, and report a high competitive
workload.
11
Appendix A:
Figure 15
Figure 28
Figure 31
12
1
Figure 4: MR Arthrogram with gadolinium contrast
Figure 55
Figure 75
Figure 65
13
Appendix B: Tables 1-36
14
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Risk Factors Leading to UCL Reconstruction and Revision Surgery

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