MRI Predictors of Failure in Non-operative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers

Abstract

Objectives:Ulnar collateral injuries (UCL) of the elbow are prevalent among professional baseball pitchers. The decision on initial operative versus nonoperative management of these injuries remains subjective in many cases, with reported success rates with nonoperative management ranging from 42 to 93% in professional throwing athletes. No studies to date have identified objective characteristics specific to success or failure of nonoperative intervention. The purpose of this study was to identify radiologic predictors for success or failure in nonoperative management of ulnar collateral ligament injuries in professional pitchers.Methods:A retrospective review of pitchers sustaining UCL injuries between 2006 and 2015 from one professional baseball organization (one major league team and all minor league teams included) was performed. UCL injuries were identified in 38 players based on clinical and radiographic findings. Six players underwent initial surgical intervention without attempted nonoperative intervention and were excluded from analysis. This left 32 (84%) professional pitchers who underwent an initial trail of nonoperative treatment for partial UCL tears. Success was defined as return to same level of play (RTSP) or higher for >1 year. Failure was defined as recurrent pain or weakness requiring surgical intervention after a minimum of 3 months’ rest when attempting a return to throw rehabilitation program. MRI findings were classified as high or low grade sprains, proximal or distal location of injury, and with or without the presence of concomitant chronic findings.Results:Of the 32 patients who underwent nonoperative management, 10 (36%) failed and required subsequent ligament reconstruction. Between the success and failure groups, there was no significant difference seen in total shoulder arc of motion (P=.7776), shoulder internal rotation deficit (P=.3846) or loss in elbow extension (P=.0644) at the time of injury. When comparing MRI findings between the groups, distal tears were found in 90% (9/10) of those who failed nonoperative management compared to 18.2% (4/22) who were successful nonoperatively (P=<.0001). No significant difference was seen with high grade tears (P=.0817) between the groups. When adjusting for age, location and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 22.7 times greater (P=.001) with distal tears. No other variable reached significance, and no combination of variables showed a greater likelihood than distal location alone.Conclusion:In professional pitchers, distal ulnar collateral ligament tears described on MRI show significantly higher rates of failure with nonoperative management compared to proximal tears. This information provides an objective measure for evaluating operative versus nonoperative management of ulnar collateral ligament injuries in throwing athletes.

Interobserver and Intraobserver Reliability of an MRI-Based Classification System for Injuries to the Ulnar Collateral Ligament

“…Despite the shortcomings of using MRI to recognize midsubstance tears, identifying proximal versus distal tears is likely to be more clinically meaningful according to preliminary results; specifically, proximal tears may be more amenable to nonoperative management and distal tears more amenable to surgical intervention. 11,15 While long-term study with a greater number of patients is needed, intraoperative correlation of UCL tear grade and location with observer MRI readings demonstrated encouraging initial accuracy that portends clinical utility of this novel MRI-based approach to classifying UCL tears.…”

“…No other study to our knowledge has attempted to classify tears of the UCL based on location and tear degree. Prospective multicenter validation of a clinical decision-making paradigm applying this MRI-based approach to identifying UCL tears is needed and already under way, enrolling a greater number of patients than cited in the reports by Lynch et al 15 and Frangiamore et al, 11 to determine the success rate of nonoperative treatment and the correlation with intraoperative findings.…”

“…This was performed to determine if distal tears could be reliably discerned given recent reports implicating distal tears with increased rates of failure in nonoperative management. 11,15 The unweighted kappa was used for the analysis of this simplified 2-stage classification. The weighted kappa values for interobserver reliability with coronal and axial views were compared with those with just coronal views (series I vs II, series III vs IV) and assessed for statistically significant differences with a t test.…”

Clinical Utility of an MRI-Based Classification System for Operative Versus Nonoperative Management of Ulnar Collateral Ligament Tears: A 2-Year Follow-up Study

“…Nonoperative treatment for patients with UCL tears has only recently been broached in the literature. 20 Ford et al 12 reported that partial UCL tears diagnosed on magnetic resonance imaging (MRI) had success with nonoperative management among professional baseball players, although the tear severity was not examined as a factor in deciding operative versus nonoperative treatment because patients with high-grade tears automatically underwent surgery. 1,8 To examine tear severity as a determinant for operative versus nonoperative treatment, an MRI-based study by Frangiamore et al 14 reviewed 32 professional baseball pitchers who underwent nonoperative management for their UCL tear.…”