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Management of Ulnar Collteral Ligament Tears: Wher ...
Management of Ulnar Collteral Ligament Tears: Where Do We Stand in 2022? (4/5)
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All right, I'm Greg Satanovich from the Ohio State University, and I'll be talking about UCL epidemiology and risk factors. These are my disclosures. The UCL is located here, and it's a common problem in baseball. This is a dramatic example, but it's often more of a chronic overuse type of thing. The UCL is vulnerable to injury in our pitchers because the extensive force generated at the medial elbow with pitching. The bony structures, muscular structures, see a lot of force. The UCL sees nearly the failure load with each pitch, although these pitchers are quite well adapted to this. This UCL is clearly vulnerable to injury. Brandon Erickson and others, Tony Romeo, performed a study a few years back looking at the rate of Tommy John surgeries or UCL reconstruction, MLB, with an exponential increase over time. This started to highlight the awareness of this injury and the prevalence of this. In MLB players with a more recent study, Chris Camp, showed that 20% of all pro players had UCL surgery. This is a very important problem for our baseball players and very prevalent. Fortunately, our operations are successful, but prevention and understanding risk factors is key here. Time out of play from MLB, this is one of the major reasons for time out of play, especially among pitchers, and it's one of the major reasons for surgery required among MLB players. In addition, Erickson, Romeo, and others looked at database of younger players and saw that there was especially a large increase in the adolescent players, the 15 to 19-year-olds, and these players may aspire to one day be MLB players, although the odds of that are relatively low. Having these injuries and surgeries at such a young age is probably not in their ideal interest in terms of their long-term athletic goals. So what are some risk factors? Jimmy Andrews and others helped us understand this on the early end, and data has refined this over the years. Earlier baseball specialization is a big risk factor, so the average age to begin focusing on baseball is dropping, and it's down to age eight in some studies. Players don't necessarily like this. They like to play other sports. They wish they could play all the other sports, especially at the younger ages, and they don't enjoy playing through pain and having people tell them they need to push through this stuff. So this is something very important that our little leagues to understand and look out for. Some of those risk factors that are very important, including higher pitch velocity, pitch counts, lots of pitching, pitching multiple days, pitching while fatigued, these are all major factors that we know that predispose to injury, and these are things where there can be interventions to mitigate this and help prevent our players from getting injured at young ages. Fastball pitch velocity is one of the major factors, and this is a study showing that this predicts a need for UCL reconstruction and MLB. Higher pitch velocity was associated with injury, and here's kind of the linear graph between pitch velocity and rate of UCL reconstruction. So the force on that ligament is higher with higher velocity, and that's one of the major factors here. Our pitchers need to throw high velocity, so we have to try to modify other things or mix in other pitches. Breaking balls aren't as important in most of the literature, although they can cause other elbow injuries, but velocity is probably the main factor in terms of the pitches. Weighted balls are known to predispose to injury. This is a study showing a six-week weighted ball throwing program, injury rate 24% from this, and in comparison, the control group did not have this rate of injuries. And this is a study from Erickson Romeo showing that training with lighter baseballs was able to achieve similar increases in velocity without the associated injury from the weighted ball. So these might be not the best strategy for increasing your velocity, especially at younger ages, and it has to be done very carefully, certainly. Glenohumeral range of motion has been implicated as a risk factor. The isolated GERD was once thought, glenohumeral internal rotation deficit, was once thought to be correlated with injury, but more recent studies, including this from Jimmy Andrews, has shown the total arc of motion may be a more important factor, and so working on maintaining that glenohumeral motion rotator cuff strength is helpful for injury prevention. This can trickle down to other parts of the kinetic chain, the core and the hips, and this is a study from Itoi showing that hip internal rotation may be associated with elbow and shoulder problems, and so working on that whole body, not just focusing on the shoulder, is critical for our pitchers. Pitch count recommendations are a major factor in the younger ages, at these little league 9, 10, 11, recommended amount of rest, recommended amount of pitches. Sticking with these is probably helpful for injury prevention, because we know that more pitches and pitching without adequate rest is a major risk factor for injury. Erickson looked at whether following the pitch counts was associated with later chance of Tommy John surgery, and there was a strong association. The people who did not follow these pitch counts had a 50% of UCL reconstruction, versus if they followed them, it was down to 2%, and so a major factor there later on in life, the attrition on that elbow, it catches up with you. There's also this unaccounted workload factor, which has been highlighted, and this is a good example. So if you're looking at pitch counts, it's counting the live game pitches, where they're on the mound, first inning, et cetera. In addition, there's bullpen pitches, there's warm-up pitches, there's other teams kids can play on, and keeping track of the total sum of pitches can be important as well, because the live game pitches may be the max effort, however, the other pitches can certainly add up and add to the fatigue. So do pitching mechanics play a role in injury? Certainly they do. There's a few studies showing this, and early trunk rotation adds force to your elbow, your shoulder, and keeping better pitching mechanics in regards to trunk rotation is helpful for reducing force on the UCL. Knee flexion angle, similarly, I won't belabor this, we need to move through to get to all the other great talks today. Fatigue impacts adolescent pitching mechanics. This is a study from Rush showing adolescent pitchers throwing an entire simulated game looking at shoulder velocity, et cetera. Knee flexion angle got worse, hip-to-shoulder separation got worse throughout the simulated games, and the pitchers got more fatigued, even though their velocity only dropped two miles an hour. So they were compensating for this by putting more stress on their elbow, more stress on their shoulder, because their mechanics deteriorated as they fatigued. So here's an example of that early rotation. There was a modified Delphi consensus statement on what are the risk factors for UCL tear, and this is recent. The risk factors are, as we highlighted before, overuse, repetitive overhead sports, early specialization in throwing, limited shoulder rotation, higher throwing velocity, poor conditioning, poor throwing mechanics, core weakness, pitching style, and prior shoulder elbow injury, and there was strong agreement among the panelists for this particular set of risk factors. And so in summary, prevention, especially at our very young ages, is the best treatment. Beater cuff, strengthening, range of motion, scapula, core, and keeping this appropriate to the age level. Let our kids enjoy baseball and have fun so they don't get injured, especially early in their career. Thank you.
Video Summary
In this video, Greg Satanovich from the Ohio State University discusses UCL epidemiology and risk factors. He highlights that UCL injuries are common in baseball, especially among pitchers, due to the extensive force generated at the medial elbow. Tommy John surgeries or UCL reconstructions have exponentially increased over time in MLB players. Risk factors for UCL tear include early baseball specialization, higher pitch velocity, pitch counts, pitching while fatigued, and the use of weighted balls. Glenohumeral range of motion and overall body strength are also important for injury prevention. Following pitch count recommendations and maintaining proper pitching mechanics are crucial. Prevention at a young age is emphasized to avoid long-term negative impacts on athletic goals.
Asset Caption
Gregory Cvetanovich, MD
Keywords
UCL epidemiology
risk factors
baseball injuries
Tommy John surgeries
pitching mechanics
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