"Elbow pain in throwers- UCL injuries"-Issue 11

Elbow pain is the most common complaint in adolescent and pre-adolescent baseball pitchers. Because of the high speed and excessive range of motion involved in pitching, the elbow joint is susceptible to unique and sport specific injuries.

As the arm reaches a fully cocked position and prepares to release the ball, an extreme stress, known as valgus stress, is generated at the elbow. This valgus stress creates a tremendous traction force along the inside of the elbow and a forceful compression on the outside of the elbow. The ligament along the inside of the elbow, known as the UCL, is the primary resistance to this stress and therefore most prone to injury.  

Overhead throwing at high speeds causes this ligament to stretch to its limit with each pitch. Injury to the ligament can occur suddenly with a high-generated force or gradually as it is exposed to repetitive stress and trauma. Both can result in instability or a tear of the UCL. 

Typically, athletes with UCL injury complain of pain along the inside of the elbow during the acceleration phase of throwing. If the injury is sudden, the athlete will hear an audible pop, followed by immediate pain and inability to continue throwing. Chronic injuries present gradually and often with pain occurring only when throwing 50-75% of maximum effort.

More than 40% of athletes with UCL injury also report symptoms of numbness and tingling in the hand or arm.  These symptoms result from friction or snapping of the ulnar nerve as it stretches across the inside of the elbow as the ball is thrown.

The diagnosis of UCL tears can be difficult to make and should begin by a thorough exam and stress x-rays of the elbow. Often an MRI is recommended to confirm a tear. Once diagnosed, treatment decisions require consideration of the individual athlete’s demands and the extent of the UCL injury.

Non-surgical treatment is attempted with partial tears and sprains of the UCL. If treatment start as symptoms begin, then it may stop the injury from progressing and allow the athlete to return to competition.  Conservative stretching and strengthening can begin once the initial pain and inflammation has been treated. Strengthening exercises focus on the muscles that help to stabilize the elbow during the late cocking and acceleration phases of throwing. If the athlete desires to return to highly competitive throwing, rest with rehabilitation of up to three months is recommended.

If the athlete fails to improve with non-surgical treatment, or the athlete has a complete tear of the UCL, surgical intervention is recommended.

Surgical management for UCL injury consists of two different methods: repair and reconstruction.  The recommendation for a direct repair of the UCL is rare and only considered if the athlete has a sudden or acute injury with no associated nerve symptoms.  In the majority of patients, a reconstruction is performed to restore stability to the inside portion of the elbow.

After surgery, the same type of rehabilitation program is used for both the repair and reconstruction techniques. Physical therapy will include a slow, gradual return to throwing over a period of 12 to 18 months.  Exercises will emphasize strengthening the specific muscles that counteract valgus stress and proper throwing mechanics will be stressed.

Prevention is key in avoiding the pain and time associated with this injury. USA Baseball recommends immediately removing a pitcher from a game when he or she complains or shows signs of arm pain.  Parents should seek medical attention if pain is not relieved within four days or if pain returns immediately the next time the player pitches.

To learn more about this injury and others, contact your local physician or physical therapist.

References:

1. Johnston et al. Elbow Injuries to the Throwing Athlete. Clinics in Sports Medicine. 1996. 307-321.
2. Fry et al. Rehabilitation Guidelines for Elbow Ulnar Collateral Ligament (UCL) Reconstruction. 
www.uwsportsmedcine.org
3. Kerry et al. Elbow medial collateral ligament injuries. Curr Rev Musculoskelet Med. 2008. 1:197-204.
4. Wilk et al. Rehabilitation of thrower's elbow. Clin Sports Med. 2004. 765-801.
5. Azar et al. Operative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Athletes. Amer Sports
Institute. 2000. 16-21.
6. www.usabaseball.com