Ulnar Collateral Ligament Injuries in Overhead Throwing Athletes
Wyatt Kurzejeski, SPT
Background:
As someone who played collegiate baseball, and cherishes my playing days dearly, this population has always held a special place in my heart. While I personally struggled with shoulder injuries throughout my playing career, I had many friends lose valuable playing time at the mercy of elbow injuries. As physical therapists, whether we go on to work directly with an athletic organization, or rather in a general outpatient orthopedic setting, we are likely to run into patients with elbow pain stemming from an injury to the UCL. Physical therapy was absolutely essential in allowing me to continue playing the sport that I loved. I am hopeful the results of this capstone project can assist not only myself, but others in our program as well, in providing a similarly valuable service to injured athletes in our future practice.
Statement of Need:
Overhead throwing athletes, particularly baseball players, are highly susceptible to injury due to the nature of the high-demand dynamic movements associated with overhand throwing. UCL injuries in the elbow can be a devastating injury for these athletes, resulting in an entire season of lost competition. Additionally, the prevalence of UCL tears has been steadily increasing over the past decade, across all levels of competition – youth, high school, collegiate, and professional. Whether conservative treatment or surgical intervention is opted for, proper physical therapy is crucial for a successful return-to-sport outcome. It is imperative that we, as physical therapists, feel competent at evaluating and treating these athletes.
Purpose:
The purpose of this project is to address a knowledge gap that I believe exists within our DPT curriculum. In my opinion, our program is lacking in specifics when it comes to diagnosing and treating injuries in athletes. While we have a good amount of course content focused on shoulder injuries – diagnostics, evaluation, and treatment, minimal clinical information is presented regarding UCL elbow injuries. For anyone who wants to work with athletes in future practice, I believe it is important to understand the current best practice approaches for UCL injuries. The products generated from this project are specifically tailored towards DPT students, and practicing physical therapists, to enhance their confidence and competence when treating athletes with UCL injuries.
Products:
Final products are linked below, and were created to serve as an adjunct to the PHYT734 Musculoskeletal II course, in the fall of the 2nd year of the UNC DPT program.
Products include: a VoiceThread presentation (approximately 1-hour in length), a comprehensive literature review, and an evaluation survey to be completed by those who view the presentation.
Evaluation:
Adjustments and additions to the materials were made along the way, as per feedback from my project advisor and committee members.
As linked above, I created an evaluation survey designed to assess the quality and effectiveness of my presentation. This form will be completed by 2nd-year DPT students who view the VoiceThread presentation during the upcoming Fall semester. I will utilize feedback from this form to enhance any future educational products.
Self-Reflection:
I found the entire process of this capstone project to be highly educational. There is no doubt that I not only expanded my clinical knowledge, but also enhanced my research evaluation skills – something I had previously felt lacking in. I feel much more confident in my ability to efficiently and effectively review current evidence surrounding a clinical question, and to apply it in practice. I cannot stress enough the importance of choosing a topic that is of personal interest, as this made the process of scouring research much more enjoyable than it otherwise could have been. I also think the way this project tied into the EBPII course in the Fall semester was an excellent way to help us build our project steadily over time. I appreciate the degree of freedom that we are granted in choosing this project, as I feel it allowed me to choose something that will directly contribute to my personal and professional development. I am hopeful the final VoiceThread presentation I have created will not only serve as useful material for future UNC DPT students, but will also be an effective tool that I will refer back to as I go forward in clinical practice. Looking back on the process, I am thankful it went very smoothly, with no major hitches, or issues with timing. There was definitely a learning curve associated with using VoiceThread tools for the first time, but the timelines we generated helped me prepare and stay on track. One of the downsides of this process, in generating materials suitable for the professional education of DPT students, a lot of the content may be too technical for other subgroups who play a critical role in the prevention of UCL injuries. However, the evidence is well-established and important, and could likely be re-worked in a manner that could inform coaches, parents, and players directly.
Acknowledgements:
First off, I would like to extend thanks to all UNC faculty who have contributed to my education over the past three years. I cannot thank our faculty enough for their time and effort.
Special thanks to my capstone advisor, Jon Hacke PT, DPT, MA. Jon was integral at helping me narrow down the focus of my project, and provided helpful instruction during the process. Additionally, Jon is the instructor for the PHYT734 course that these materials were designed to supplement.
I would also like to thank my committee members, Joe Orbaczewski PT, DPT, CSCS and Stephanie Milosovic PT, DPT. Both Joe and Stephanie provided useful feedback and instruction that contributed to my final products.
Thank you to all three of these individuals for being willing to serve on my committee, and for taking time out of their busy schedules to offer assistance and guidance. Please know that your contributions are deeply appreciated.
References:
- Dugas J, Chronister J, Cain EL, Andrews JR. Ulnar collateral ligament in the overhead athlete: a current review. Sports Med. Arthrosc. 2014;22(3):169-182. doi:10.1097/JSA.0000000000000033.
- Patel RM, Lynch TS, Amin NH, Calabrese G, Gryzlo SM, Schickendantz MS. The thrower’s elbow. Orthop Clin North Am 2014;45(3):355-376. doi:10.1016/j.ocl.2014.03.007.
- Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am. J. Sports Med. 2004;32(5):1158-1164. doi:10.1177/0363546503262166.
- Rothermich MA, Conte SA, Aune KT, Fleisig GS, Cain EL, Dugas JR. Incidence of elbow ulnar collateral ligament surgery in collegiate baseball players. Orthop. J. Sports Med. 2018;6(4):2325967118764657. doi:10.1177/2325967118764657.
- DeFroda SF, Kriz PK, Hall AM, Zurakowski D, Fadale PD. Risk stratification for ulnar collateral ligament injury in major league baseball players: A retrospective study from 2007 to 2014. Orthop. J. Sports Med. 2016;4(2):2325967115627126. doi:10.1177/2325967115627126.
- Chauhan A, Chalmers PN, McQueen PD, et al. Outcomes of Non-Operatively Treated Elbow Ulnar Collateral Ligament Injuries in Professional Baseball Players by Magnetic Resonance Imaging Tear Grade and Location. Orthop. J. Sports Med. 2019;7(7_suppl5):2325967119S0031. doi:10.1177/2325967119S00311.
- Frangiamore SJ, Lynch TS, Vaughn MD, et al. Magnetic resonance imaging predictors of failure in the nonoperative management of ulnar collateral ligament injuries in professional baseball pitchers. Am. J. Sports Med. 2017;45(8):1783-1789. doi:10.1177/0363546517699832.
- Dines JS, Williams PN, ElAttrache N, et al. Platelet-Rich Plasma Can Be Used to Successfully Treat Elbow Ulnar Collateral Ligament Insufficiency in High-Level Throwers. Am J Orthop 2016;45(5):296-300.
- Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma. Am. J. Sports Med. 2013;41(7):1689-1694. doi:10.1177/0363546513487979.
- Erickson BJ, Chalmers PN, Bush-Joseph CA, Verma NN, Romeo AA. Ulnar collateral ligament reconstruction of the elbow: A systematic review of the literature. Orthop. J. Sports Med. 2015;3(12):2325967115618914. doi:10.1177/2325967115618914.
- Keller RA, Steffes M, Zhuo D, Bey MJ, Moutzouros V. The effects of ulnar collateral reconstruction on major league pitching performance. Orthop. J. Sports Med. 2014;2(7_suppl2):2325967114S0003. doi:10.1177/2325967114S00035.
- Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports Health 2009;1(4):301-313. doi:10.1177/1941738109338553.
- Andrews Protocol: Post-Operative Rehabilitation Protocol Following Ulnar Collateral Ligament Reconstruction Using Autogenous Palmaris Longus Graft. UVA Hand Center – Therapy. Available at: https://med.virginia.edu/orthopaedic-surgery/wp-content/uploads/sites/242/2015/11/AndrewsUCLProtocol.pdf. Accessed March 16, 2020.
- Reinold MM, Macrina LC, Fleisig GS, Aune K, Andrews JR. Effect of a 6-Week Weighted Baseball Throwing Program on Pitch Velocity, Pitching Arm Biomechanics, Passive Range of Motion, and Injury Rates. Sports Health 2018;10(4):327-333. doi:10.1177/1941738118779909.
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5 Responses to “UCL Injuries in Overhead Throwers”
Wyatt Kurzejeski
Gabe,
Thank you for your kind words and well thought out feedback. You are absolutely correct that (like many other findings such as osteophytes or MRI changes) GIRD is frequently asymptomatic. You are right that total arc of motion is a much better clinical indicator in overhead throwers, and is frequently “normal” even in the presence of GIRD.
Great idea about the resource for educating coaches! I didn’t even think of that, since my presentation was geared towards PT students, but I agree this would be a great product that could bridge the gap, and directly aid in prevention of UCL injuries; after all, coaches have a lot more influence and time with non-injured athletes than PT’s do!
Thank you,
Wyatt
dimockgj
Wyatt,
Great job on your Capstone project! You provide a thorough overview of UCL injuries and highlight the most physical therapy relevant components. I was impressed by your comfort level with the Voicethread presentation as you were engaging and added interesting information in addition to what was on the slide. You also covered many of the topics such as weighted ball programs in a nuanced manner rather than simply categorizing them as good or bad as is common in the baseball world. This allows players to make well-informed decisions that balance the risk vs reward. Below are a couple of recommendations that may add to your impressive project:
1. Consider adding a caveat to the GIRD emphasis. GIRD is commonly a non-pathologic finding in overhead athletes due to adaptive glenohumeral retrotorsion. However, an IR deficit of >20 degrees is considered a risk factor. Additionally, total arc motion may be a better indicator when comparing the throwing vs non-throwing shoulder. Decreased overall total arc motion in the throwing shoulder should certainly be addressed as this would not be due to the glenohumeral retrotorsion mentioned above
2. You demonstrate a great understanding of the mechanical flaws that are at the root of many UCL injuries. However, many coaches are unable to effectively teach biomechanics-based throwing mechanics because of a lack of understanding. Creating a resource for coaches with specific drills and movements to promote better throwing mechanics could be valuable from someone with your skillset.
Thank you again for a phenomenal resource that I will refer to throughout my career when treating patients with UCL injuries!
Wyatt Kurzejeski
Mara and Dr. Thorpe,
Thank you both for your kind feedback, and for taking the time to view my presentation. I am glad to hear that you both agree that it will be a helpful addition to the curriculum!
Wyatt
Debbie Thorpe
Wyatt
Very nice project on UCL injuries in overhead throwing athletes! I really enjoyed listening to your presentation. It will be a valuable addition to the curriculum in PHYT 734.
Best Wishes..
argyriou
Wyatt, I am glad to see that this project enhanced your personal growth. You did an excellent job in your Voice Thread presentation – keeping it straight forward but also going in more depth in pertinent areas. I have no doubt that it will be very much appreciated by UNC’s DPT students in the future and that it will help bridge the gap you talked about regarding the lack of content for the evaluation and treatment of athletes. I also think it will increase awareness in this area and motivate students and faculty to increase the PT content specific to the athletic population. Thank you for all the great information, and great job!