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IC 207-2023: Management of Ulnar Collateral Ligame ...
IC 207 - Management of Ulnar Collateral Ligament T ...
IC 207 - Management of Ulnar Collateral Ligament Tears: Where Do We Stand in 2023? (4/6)
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Video Transcription
All right. Thank you, Brandon. And we're going to talk briefly about ulnar collateral ligament epidemiology and risk factors. That was my task. And that's our SportsMed building, always sunny in Ohio. We have disclosures. They're on the website. So the ulnar collateral ligament is defined by these three bands, anterior, posterior, transverse band. The anterior band is the main one that's relevant for pitching. And so that's what we'll be talking about reconstructing. The UCL is vulnerable because a lot of force is generated with the elbow with each pitch. And it gets up closer to failure loads with the pitches. Pitchers are able to remarkably adapt to this and perform at a high level. But it is a weak link in the elbow structure. After Tommy John surgery and Major League Baseball, you've seen a rapid rise in these surgeries over the recent decades. And this is due to a combination of factors that we'll discuss. But there's no doubt that this is an increasingly common problem encountered in our baseball athletes as well as some other sports. And it is increasing surgical procedure year by year. Chris Camp and others looked at prevalence of medial ulnar collateral ligament surgery in professional baseball players, finding roughly a quarter of all pro players had UCL surgery. And so you can see this has increased from 2012 to 2018. And this is an important thing to try to prevent as best we can and then understand these injuries and the nature of returning to sport afterwards. And time out of play for Major or Minor League Baseball, ulnar collateral ligament injury was not number one. But it was number six, resulting in a substantial amount of injuries, time, and cost to the players and the organizations. Injuries in ulnar collateral ligament injury also extend to younger ages. And this is increasingly concerning. There was a dramatic increase in UCLR in the teenage population. And these players are still playing in travel leagues or school teams and hopeful to maybe make it to play in college and beyond. And it's really unfortunate for them to be having increasing rates of these surgeries at such a young age. So what do we know? Here's some of the risk factors. One issue with risk factor for UCL injury is earlier baseball specialization. Age to specialize sports has dropped over decades and there's lots of factors involved. And this is not always welcomed by the players. Players often would prefer to be able to play some more sports, kind of try different things. Some were hearing from their coaches that they should stop playing other sports. Some were told they should kind of play through pain or things like that. And this isn't fun. And this is supposed to be a fun game and a fun sport and activity. And if we're doing this at younger ages, this is really not the right thing for our kids and our athletes. Risk factors, we know higher velocity, higher pitch counts, pitching consecutive days, pitching when fatigued, geographical factors, including warmer weather are definitely relevant. And this is always an evolving science. Fastball pitch velocity was one of the factors that's been shown to predict UCL reconstruction in major league baseball players. And the velocity more than sort of the type of pitch has been pretty consistently implicated with UCL injuries. So higher velocity, higher rate of subsequent UCL reconstruction. Breaking balls can certainly cause some elbow problems, but not as important of a factor as velocity. And some studies dispute whether it has much of a role at all. So I think the number of pitches, the velocity, pitching with fatigue, poor mechanics are key factors, not as much the breaking ball, but it all has to be with a balance as players grow and evolve and train. Weighted balls certainly can cause some problems. Weighted balls sometimes have benefit on velocity, but there's other ways to achieve velocity without quite the same risk of injury. And 24% injury in the rate in the weighted ball group, really something a lot of people have shied away from increasingly over the years and other ways to train and gain the velocity. So Brandon's study, training with lighter baseballs, you can achieve the same increase in velocity without this associated injury risk. And the sole emphasis on velocity is potentially problematic here. And I think it's good to help people work on mechanics and pitch control and things like that. Velocity always is going to come into play because it's going to help you to get the batters out. But we have to kind of balance this with other factors. There's certainly some impact of other joints in the kinetic chain. So hip internal rotation, shoulder internal rotation implicated. And that puts an emphasis on keeping track of the entire pitch mechanics and the entire kinetic chain in treating and rehabbing pitchers and also preventing these types of injuries. So this is restriction in hip internal rotation is associated with shoulder elbow problems. And you would think the hip is pretty far removed. But certainly if you can work through all these other things that impact the pitch motion, you can help to reduce the risk of injury. We do think that pitch counts are effective for preventing UCL injury. So this has been increasingly recognized over the year and there's guidelines for pitch counts. It's important that we try to follow these and this can help prevent injury and keep the workload to a manageable level. Brandon and Peter and Tony published a study on whether Little League baseballers who were following pitch count guidelines or exceeding them had a chance of higher risk of injury down the road. And for those who didn't follow the guidelines in Little League were much higher rate of Tommy John surgery versus those who did follow the pitch counts. And this is a pretty striking difference there. There's also workload that we have to keep track of that doesn't go into the specific pitch counts. And this is something that I think is important to work with on pitching coaches and trainers. There's live game pitches making up a little over half of the pitches that are happening in a high school baseball pitcher. But there's also bullpen pitches. There's warmup pitches. They could be in two or three leagues simultaneously or overlapping and the pitch counts in one league might not always get kept track of with pitch counts in another league. And so we have to really try to keep an eye on that total workload. There are certainly some risk factors for pitching mechanics increasing UCL injury. So elbow varus torque, shoulder external rotation torque and pitch velocity, pretty obvious ones. In terms of mechanics, early trunk rotation is one of the factors that's implicated. So if you lose this hip and shoulder separation versus maintain it, you're concentrating more forces across the upper extremity. And if you maintain it appropriately, you can better smooth those forces through the pitching motion and not lead to that stress concentration on the elbow. Similarly, the knee flexion angle is important here. And these are things that can be modified and worked on to help reduce the strain on the elbow. Fatigue we know is relevant to pitching mechanics. And that's one of the reasons why we think pitching to higher numbers of pitch counts and pitching consecutive days without adequate rest is important. And we do see these pitching mechanics start to break down as pitchers get later in the games. The hip and shoulder separation, the knee flexion angle, these can start to lose their good form as they get tired. And this is going to put them at higher risk of injury. So here's an example of the shoulder separation. And so there was a Delphi consensus statement on what are the risk factors, kind of summarizing some of the things we've just talked about. This includes overuse, repetitive overhead sports, early specialization, limited shoulder rotation, higher throwing velocity, poor conditioning, poor mechanics, core weakness, hip trunk deficits, pitching style, and prior injury. And this was a high level of agreement from the consensus statement group. So these are some of the things. And luckily, some of these we can really modify and intervene on. It's not always easy to do. But I think it's worthwhile in the end. So prevention is our best treatment. And we'll get on to doing some discussion of what happens if prevention fails. Thanks.
Video Summary
The video discusses the epidemiology and risk factors of ulnar collateral ligament (UCL) injuries, particularly in baseball pitchers. UCL is vulnerable due to the high force generated during pitching, and the surgery to reconstruct it has seen a rapid rise in recent decades. Risk factors include earlier specialization in baseball, higher pitch velocity, higher pitch counts, pitching consecutive days, pitching when fatigued, geographical factors (warmer weather), and poor mechanics. Pitch counts and workload need to be monitored to prevent injuries. Other factors like hip and shoulder rotation, knee flexion angle, and fatigue also play a role in UCL injuries. Prevention is the best treatment. (No credits granted)
Asset Caption
Gregory Cvetanovich, MD
Keywords
epidemiology
risk factors
ulnar collateral ligament injuries
baseball pitchers
UCL surgery
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