Medial Elbow Instability Resulting From Partial Tears of the Ulnar Collateral Ligament: Stress Ultrasound in a Cadaveric Model

Return to play after UCL injury in gymnasts

BACKGROUND

Injuries to the ulnar collateral ligament (UCL) are commonly reported in traditional overhead sports. Conversely, there is a lack of evidence outlining management and return to play (RTP) outcomes for gymnasts. This study aimed to evaluate RTP and patient reported outcomes (PROs) in gymnasts after operative and non-operative treatment of UCL injuries.

METHODS

Gymnasts who presented with UCL injury and underwent operative and non-operative treatment were evaluated. Patient reported outcomes were collected via telephone: Conway-Jobe Scale, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) Score, Mayo Elbow Performance (MEP) Score, and quick DASH (qDASH) and Timmerman-Andrews (TA) Elbow Score.

RESULTS

Nine patients met inclusion criteria and were available for follow-up. Five were initially treated operatively and four were initially treated non-operatively. The operative group initially consisted of three ulnar collateral ligament reconstructions (UCLR) and two UCL repairs with internal bracing. One patient crossed over to the operative group after failing non-operative treatment and underwent UCLR four months post injury. Overall, 66.7% and 100% of operatively and non-operatively treated gymnasts were able to return to play, respectively. At final follow-up, the operative groups' mean KJOC, MEP, TA, and qDASH scores were: 68.4 ± 7.7, 97.5 ± 2.7, 90.8 ± 10.7, and 1.9 ± 3.0, respectively. For the non-operative group, the mean scores were 67.4 ± 9.0, 71.7 ± 5.8, 71.7 ± 14.4, and 11.4 ± 9.9, respectively. Treatment satisfaction for the operative group was 81.7 ± 27.5 compared to 80.6 ± 34.5 in the non-operative group. Odds ratios indicated no differences between groups.

CONCLUSION

Both operative and non-operative interventions for UCL injuries in gymnasts can provide favorable outcomes with respect to return to play and subjective patient-reported outcomes. Further research is warranted to determine optimal treatment, especially regarding indications for operative vs. nonoperative treatment, of UCL injury based on injury severity and location in gymnasts.

LEVEL OF EVIDENCE

Case series; Level III Evidence.

Chronic Structural Adaptations of the Shoulder and Elbow Are Correlated in Professional Baseball Pitchers

BACKGROUND

Pitchers with deficits in total shoulder rotation range of motion (ROM) are 2.6 times more likely to experience an elbow injury. Despite the effects of shoulder ROM on elbow injury, it is currently unclear whether specific tissue adaptations of the shoulder relate to the tissue adaptations of the elbow in baseball pitchers.

PURPOSE/HYPOTHESIS

The purpose was to evaluate the relationship between chronic structural adaptations of the shoulder (humeral retroversion [HR], posterior capsule thickness [PCT], infraspinatus/teres minor pennation angle, and muscle thickness) and chronic structural adaptations of the elbow (ulnar collateral ligament [UCL] thickness, ulnohumeral joint laxity with valgus stress, and ulnar nerve cross-sectional area) in professional baseball pitchers. It was hypothesized that chronic adaptations of HR and PCT would relate to structural adaptations of the elbow.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Healthy minor league right-handed baseball pitchers from a single professional baseball organization were enrolled during 2022 preseason medical evaluations. Enrolled pitchers underwent bilateral shoulder ultrasound examination of HR, PCT, and posterior rotator cuff pennation angle and muscle thickness as well as bilateral elbow ultrasound examination of the ulnar nerve, UCL thickness, and ulnohumeral joint gapping using the Telos device. The difference in ulnohumeral joint gapping from stressed (150 N) to unstressed (ie, delta value) was calculated. Bilateral differences in every included measure were calculated and used for analysis to more closely isolate chronic adaptations. Multivariate stepwise regressions were performed to determine whether the chronic structural and clinical (strength and ROM) shoulder adaptations were related to structural adaptations of the elbow.

RESULTS

Overall, 40 right-handed professional baseball pitchers with a mean age of 22 ± 3 years were included. A significant positive relationship was observed between preseason structural adaptations of UCL thickness and PCT (R = 0.344; R2 = 0.118; P = .030) as well as between chronic structural adaptations of ulnar nerve cross-sectional area and teres minor muscle thickness (R = 0.387; R2 = 0.150; P = .020). No statistically significant relationships were found between chronic structural adaptations of the shoulder and delta ulnohumeral joint gapping (all P > .05) or between chronic adaptations in clinical measures (strength and ROM) of the shoulder and chronic structural adaptations of the elbow (all P > .05).

CONCLUSION

Positive relationships between chronic adaptations of UCL thickness and PCT, as well as between ulnar nerve cross-sectional area and teres minor MT, were observed in asymptomatic minor league pitchers. However, no significant relationships between adaptations in shoulder strength or ROM were related to chronic structural adaptations of the elbow.

Editorial Commentary: Elbow Ulnar Collateral Ligament Repair With Suture Tape Augmentation Versus Reconstruction Should Be Determined Using Precise Imaging and Indications

Current surgical treatment options for ulnar collateral ligament (UCL) injury of the elbow include both reconstruction and repair. A growing amount of research has evaluated the outcomes of these various techniques in a variety of study designs. Large national database assessment indicates that overall failure rates are low and complication rates are similar between UCL reconstruction and UCL repair techniques. In addition, although the incidence of revision UCL surgery is low, UCL repair is associated with a significantly greater risk of revision than UCL reconstruction. This information is important in counseling our patients and urges us to perform higher-level, comparative research of these 2 surgical techniques in order to more precisely sculpt the optimal treatment algorithm for UCL injury. In my experience, preoperative advanced imaging including magnetic resonance imaging, magnetic resonance arthrography, and stress ultrasound are invaluable in determining the location and degree of UCL injury and, equally importantly, the status of the remaining ligament. These are key factors in deciding whether a particular patient is appropriate for UCL reconstruction or repair according to the indications defined by Dugas (with suture tape augmentation): "complete or partial avulsion of the UCL from either the sublime tubercle or medial epicondyle, without evidence of poor tissue quality of the ligament."

Recovery of the Medial Elbow Joint in the 24-Hour Period After Repetitive Pitching in High School Players

BACKGROUND

Repetitive pitching causes immediate changes in the medial elbow joint. However, the recovery process from these changes is not clear.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate the recovery of the medial elbow joint in the 24-hour period after pitching. The hypothesis was that while some recovery will occur at 24 hours after repetitive pitching, this would not be a complete return to baseline.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 26 high school baseball pitchers participated (mean age, 16.0 ± 0.5 years). Participants threw 100 pitches (5 sets of 20 pitches). Medial elbow joint width as well as strain ratios of the ulnar collateral ligament (UCL) and forearm flexor-pronator muscles (FPMs) were measured and followed for 24 hours after pitching. The data before pitching and at each time point after pitching were compared. The standard error of measurement (SEM) and minimal detectable change with 95% confidence interval (MDC95) were calculated using measurements before pitching.

RESULTS

The medial elbow joint width significantly increased by 0.84 mm immediately after pitching (P < .05), but this was not maintained at 24 hours. The UCL strain ratio significantly decreased by 1.64 immediately after pitching (P < .05), but this was not maintained at 18 hours after pitching. The strain ratio of the FPMs significantly decreased by 0.09 immediately after pitching (P < .05) but significantly increased by 0.13 at 24 hours (P < .05). The SEM for medial elbow joint width was 0.06 mm, and the MDC95 was 0.18 mm (maximum change: 0.84 mm immediately after pitching). The SEM for UCL strain ratio was 0.85, and the MDC95 was 2.35 (maximum change: 1.64 immediately after pitching). The SEM for strain ratio of the FPMs was 0.08, and the MDC95 was 0.22 (maximum change: 0.13 at 24 hours).

CONCLUSION

After 100 pitches, stability against elbow valgus laxity recovered within 24 hours. UCL and FPMs showed statistical characteristic changes, but those changes were within the minimal detectable change.

CLINICAL RELEVANCE

Pitchers' medial elbow joint tissue recovered to baseline at 24 hours after pitching. This suggests that it may be acceptable to resume low-intensity throwing after a 24-hour rest period after 100 repetitive pitches while also considering the condition of the rest of the body.

Return to Play in the Professional Athlete

The management of any injury in elite athletes poses unique challenges distinct from the general population because the goal is rapid recovery and return to play (RTP) while simultaneously managing residual symptoms and minimizing risk of reinjury. The time required for treatment, recovery, and return to peak performance can have consequences for both the athlete and his or her team: financial implications, psychological stressors, team dynamics, and future performance. RTP after an injury in the professional athlete requires a complex decision-making process with many stakeholders. Several factors influence this decision, not the least of which is the type and mechanism of injury. This article provides an overview of the RTP process including nonmedical factors that may influence this decision, common injuries seen in professional athletes, injury patterns particular to certain popular sports, and imaging guidelines for such injuries.

In Vivo Effect of Partial Ulnar Collateral Ligament Tear Location on Ulnohumeral Joint Gapping With Stress Ultrasound in Baseball Pitchers

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.

Ultrasonography of the pediatric elbow

Ultrasound of the elbow can be incorporated into routine pediatric practice in the radiology department, emergency department, orthopedic clinic, and interventional suite. Ultrasound is complementary to radiography and magnetic resonance imaging for the evaluation of elbow pain in athletes with overhead activities or valgus stress, focusing on the ulnar collateral ligament medially and capitellum laterally. As a primary imaging modality, ultrasound can be used for a variety of indications including inflammatory arthritis, fracture diagnosis, and ulnar neuritis/subluxation. Ultrasound is also well-suited to guide diagnostic and therapeutic elbow joint interventions with precise localization of anatomic landmarks and needle placement. Here, we describe technical aspects of elbow ultrasound and illustrate its application in pediatric patients from infants to teen athletes.

Orthobiologic Treatment of Throwing Related Injuries in Sport: A Focused Review of the Published Literature

ABSTRACT

Because of the growth and development of orthobiologics, in particular platelet-rich plasma, as a potential treatment modality in sports related injuries, it is imperative that providers are aware of the up-to-date published data on the usage of this treatment. While some data are promising, prospective studies are needed to determine the effectiveness of platelet-rich plasma treatment for throwing related injuries. There are limitations with all of the published data that include their retrospective nature, heterogeneity between study designs, and platelet-rich plasma characteristics if reported. While platelet-rich plasma may be used as a likely safe adjuvant to conservative and surgical treatments, prospective randomized controlled studies using appropriately reported platelet-rich plasma concentrations and characteristics will help physicians make more definitive recommendations in regard to platelet-rich plasma treatment. Based on the currently available published data, this treatment may be trialed in the right setting and based on severity and location of injury.

The Role of Ultrasound in the Evaluation of Elbow Medial Ulnar Collateral Ligament Injuries in Throwing Athletes

PURPOSE OF REVIEW

Although ultrasound (US) imaging is commonly used to evaluate the elbow medial ulnar collateral ligament (mUCL) in throwing athletes, significant technical heterogeneity exists in the published literature and in practice. This has resulted in variable and often ambiguous US diagnostic criteria for mUCL injury. This review summarizes the literature on sonographic evaluation of the mUCL and outlines recommendations for consistent descriptive terminology, as well as future clinical and research applications.

RECENT FINDINGS

Both acute and chronic throwing loads in overhead athletes cause the mUCL to become thicker and more lax on stress testing, and these changes tend to revert after a period of prolonged rest. Stress US (SUS) can aid in the diagnosis of mUCL tears and may help identify athletes at risk of mUCL injury. Variability exists in terminology, elbow flexion angle, amount of stress applied, and technique of stress testing. Recent studies have suggested an injured elbow stress delta (SD-change in ulnohumeral joint (UHJ) space with valgus stress) of 2.4 mm and a stress delta difference (SDD-side-side difference in SD) of 1 mm each denote abnormal UHJ laxity due to mUCL injury. US imaging is a powerful and widely accessible tool in the evaluation elbow mUCL injuries. Sonologists should consider how their US techniques compare with published methods and use caution when applying diagnostic criteria outside of those circumstances. Currently, an SD of 2.4 mm and an SDD of 1 mm provide the best diagnostic accuracy for mUCL tears requiring surgery. Finally, preliminary work suggests that shear wave elastography may be helpful in evaluating the biomechanical properties of the mUCL, but additional research is needed.

Does proximal versus distal injury location of the medial ulnar collateral ligament of the elbow differentially impact elbow stability? An ultrasound-guided and robot-assisted biomechanical study

BACKGROUND

The location (proximal vs. distal) of elbow medial ulnar collateral ligament (MUCL) tears impacts clinical outcomes of nonoperative treatment. The purposes of our study were to (1) determine whether selective releases of the MUCL could be performed under ultrasound (US) guidance without disrupting overlying soft tissues, (2) assess the difference in medial elbow stability for proximal and distal releases of the MUCL using stress US and a robotic testing device, and (3) elucidate the flexion angle that resulted in the greatest amount of medial elbow laxity after MUCL injury.

METHODS

Sixteen paired, fresh-frozen elbow specimens were used. Valgus laxity was evaluated with both US and robotic-assisted measurements before and after selective MUCL releases. A percutaneous US-guided technique was used to perform proximal MUCL releases in 8 elbows and to perform distal MUCL releases in their matched pairs. The robot was used to determine the elbow flexion angle at which the maximum valgus displacement occurred for both proximally and distally released specimens. Open dissection was then performed to assess the accuracy of the percutaneous releases.

RESULTS

Percutaneous US-guided releases were successfully performed in 15 of 16 specimens. The proximal release resulted in greater valgus angle displacement (11° ± 2°) than the distal release (8° ± 2°) between flexion angles of 30° and 70° (P < .0001 at 30°, P < .0001 at 40°, P = .001 at 50°, P = .005 at 60°, and P = .020 at 70°). Valgus displacement between release locations did not reach the level of statistical significance between 80° and 120° (P = .051 at 80°, P = .131 at 90°, P = .245 at 100°, P = .400 at 110°, and P = .532 at 120°). When we compared the values for the mean increase in US delta gap (stressed - supported state) from before to after MUCL release, the proximally released elbows had larger increases than the distally released elbows (5.0 mm proximal vs. 3.7 mm distal, P = .032). After MUCL release, maximum mean valgus displacement occurred at 49° of flexion.

CONCLUSIONS

US-guided selective releases of the MUCL can be performed reliably without violating the overlying musculature. Valgus instability is not of greater magnitude for distal releases when compared with proximal releases. This findings suggests there must be alternative factors to explain the difference in clinical prognosis between distal and proximal tears. The observed flexion angle for maximum valgus laxity could have important implications for elbow positioning during US or fluoroscopic stress examination, as well as surgical repair or reconstruction of the MUCL.

Computer Intelligent Algorithm in the Recovery of the Elbow Joint Sports Injury Model

In this study, the inverse kinematics mathematics computer intelligent algorithm model is used to study the sports injuries of the elbow joint of adolescents. At the same time, we simulated the movement parameter changes during the rehabilitation training of the patient's wrist and proposed a joint angular velocity function based on cubic fitting. Research has found that when the training scene changes greatly or the target task is changed, the smoothness of the elbow joint movement will change. The research conclusions of this article provide a theoretical basis for the selection of man-machine action points and the formulation of rehabilitation training methods. This article establishes the degree-of-freedom simulation model of the operating arm, which is the number of independent position variables in the operating arm, and these position variables determine the positions of all parts in the mechanism.