Baseball season is upon us. Given I spent time in the MLB, this is always a part of the year I love. Unfortunately for pitchers, it comes with one of the worst injuries possible for a throwing athlete; a UCL sprain.
Ulnar collateral ligament (UCL) sprains are a common injury among athletes, especially those who participate in throwing sports like baseball. If you’re an athlete who has experienced a UCL sprain, you may be familiar with the term Tommy John surgery.
UCL Anatomy
The UCL provides stability to the medial elbow against valgus stress. It works very similarly to the MCL of the knee. It originates on the distal end of the humerus (the upper arm bone) and attaches to the ulna (the pinky side forearm bone).
Specifically it attaches to the medial epicondyle. This is a shared attachment point to the wrist flexor bundle which will be more relevant later on in this post. It consists of 3 different bands; the anterior (strongest), the posterior and the transverse.
How Does The UCL Get Sprained?
Damage to the UCL occurs almost exclusively from valgus force to the elbow. It can happen via some hyperextension injuries but we’ll briefly touch on that as a UCL injury in a non thrower is a non issue. This valgus force can occur when the hand is fixed on the ground and external force is applied to the outside of the elbow.
The primary way a UCL is sprained is as a result of throwing a baseball. The force exerted on the medial elbow every time a baseball is thrown exceeds the tensile capacity of the UCL, yet it doesn’t tear every throw.
Read that again. Every time you throw a baseball, its enough force to tear the ligament.
This is because the wrist flexors provide additional stability to the elbow and absorb most of the force.
In fact, read this study (link) on how having weaker wrist flexors leads to a higher risk of UCL sprain. This study will tie directly into the prevention of a UCL sprain
How Can Your Prevent A UCL Sprain?
First off, no injury can be fully prevented, but the risk can be reduced. Since the wrist flexors act as secondary stabilizers of the medial elbow, these will be the focus.
Grip strength is one of the best objective measurements we can use regarding UCL sprain prevention. In the MLB, we would assess grip strength as a pre season baseline. Throughout the course of the season, those measurements would be retaken.
If there was a decrease in strength that was statistically significant, interventions would be done to improve grip strength.
When a UCL tears, it is an acute moment caused by chronic wear and tear that degrades the medial elbow stability.
Diagnosis Of A UCL Sprain
The gold standard for a UCL sprain is going to be an MRI with contrast. What this means is that a dye is injected directly into the UCL. When the image is taken, the dye can be seen leaking out through the damaged UCL.
There are a few clinical exams that can be done but they are far less reliable. We’ll look at two below. Textbooks will tell you a positive test is pain and laxity (looseness of the ligament)
When it comes to real world application, this is BS. You will never feel any instability or laxity in the elbow from a UCL sprain. The amount of movement present when the UCL is completely severed is 1mm
Find me one person who claims they can tell the difference between 1mm and 0mm with their bare hands and I will show you a liar
As a result, a clinical exam will look for pain in the test, and if positive, refer out for an MRI.
These tests are never conclusive. They are a simple if then formula
IF the test causes pain, THEN you get an MRI
UCL Rehab And Tommy John Surgery
This is where extreme nuance comes into the equation. There is not a single black and white answer here.
Conservative Rehab
We’ll get non throwers out of the way here first, If you are a non throwing athlete, you will almost never need Tommy John surgery as you can get the secondary elbow stabilizers strong enough so conservative rehab is usually the answer here.
Here’s where the conversation gets difficult. In the event that the UCL is not fully torn (grade 1 or 2) you can have success with conservative rehab.
However, there is no guarantee this will work and you will need several months of rehab plus a return to throwing program. The problem is that this can take up to 6 months.
The risk a pitcher would run is taking 6 months to rehab, the rehab not working and then needing surgery. Tommy John surgery can take up to 12-18 months in and of itself.
So now you add 6 more months and you could be looking at almost 2 years before a return to competition which is not even a guarantee that pre surgery levels are ever achieved.
Surgery
Caveat,
I am not a surgeon. I will BRIEFLY touch on the surgery here
Tommy John surgery is the default option for UCL sprains in throwing athletes. It has anywhere from an 80-95% return to play rate. However, there is a 20% risk that pre surgery competitive levels are never restored.
In short, Tommy John surgery works by removing a tendon from the forearm (Palmaris Longus). Fun fact, about 1/3 people don’t have one. Some people only have one (the guy writing this doesn’t have any).
To see if you have one, pinch your fingers together and flex your wrist. You should see the tendon pop out of your wrist
In the case the athlete doesn’t have one, they usually remove a toe tendon and then graft that to where the UCL once was.
There are 2 techniques for Tommy John surgery, the Jobe Technique and the Docking Technique. I won’t bore you with a ton of the details but the newer Docking technique does not move the ulnar nerve so there have been some better results reported.
This technique is newer and does not yet have the massive data behind it like the Jobe Technique.
A UCL sprain and Tommy John surgery go hand in hand. 2 of the most feared words a baseball player can hear. Although recovery timelines are getting better, this is an injury you want no part of. It’s guaranteed you will miss at least one calendar year
Since baseball season is in full swing, let me know if there’s other baseball related injuries you want broken down.