Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis

Gopinatth, Varun; Batra, Anjay K.; Khan, Zeeshan A.; Jackson, Garrett R.; Jawanda, Harkirat; Mameri, Enzo S.; McCormick, Johnathon R.; Knapik, Derrick M.; Chahla, Jorge; Verma, Nikhil N.

doi:10.1177/03635465221150507

Cited by 9 publications

(5 citation statements)

References 47 publications

(113 reference statements)

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“…Distal tears have been found to be significantly more likely to fail nonoperative management and have a poorer prognosis when compared with proximal tears, potentially due to decreased vascularity around the distal segment of the ligament. 6,15,16,38 Given this association, it is possible that the mechanism of injury may have a prognostic role in these patients. Further studies with larger sample sizes are needed to validate these findings.…”

Section: Discussionmentioning

confidence: 99%

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents

Sinha,

Wyatt,

Althoff

et al. 2024

Am J Sports Med

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Background: Although pediatric medial epicondylar fractures and apophysitis are well studied, patterns of subapophyseal avulsion and ligamentous injuries of the medial elbow in this population merit investigation to inform optimal treatment strategies. Purpose: To describe the occurrence and demographic correlates of ulnar collateral ligament (UCL) avulsion and soft tissue injuries of the pediatric and adolescent elbow. Study Design: Cross-sectional study; Level of evidence, 3. Methods: An institutional review board–approved review was conducted to identify consecutive patients with medial elbow injuries treated in a tertiary pediatric sports medicine practice between 2016 and 2021. Radiographs were obtained during injury evaluation, and patients with nondisplaced medial epicondylar apophysitis and complete epicondylar fracture were excluded, resulting in 150 patients with soft tissue injuries occurring distal to the medial epicondyle apophysis (subapophyseal) for study. Radiographs were evaluated for bony avulsion of the UCL from either the medial epicondyle proximally or the ulnar sublime tubercle distally. Injuries without radiographic evidence of bony avulsion, but with clinical examination findings consistent with ligamentous injury, were classified as radiographically negative UCL injuries, and magnetic resonance imaging (MRI) was performed to further evaluate these injuries if moderate to severe medial swelling of the elbow or significant concern for medial structural injury was present on examination. These MRI scans were evaluated to classify the UCL injury and assess for periosteal or cartilaginous avulsions. Results: A total of 150 patients (mean age, 12.5 ± 3.4 years; 70 female), 55% (150/274) of the entire medial elbow injury population, had a subapophyseal injury. Of these patients, 62 had a bony avulsion detected on radiograph, and 88 had a radiographically negative injury. In addition to the 62 radiographic avulsions, the 61 MRI scans obtained on those radiographically negative injuries revealed 33 complete UCL disruptions, resulting in 63.3% (95/150) of patients sustaining a complete ligamentous disruption. With the MRI scans, 37 (61%) cases of cartilaginous or periosteal avulsion of the UCL were diagnosed. Overall, 66% of all 150 subapophyseal injuries had a bony, cartilaginous, or periosteal UCL avulsion. Patients with cartilaginous (mean age, 10.3 years) and bony (mean age, 10.6 years) avulsions were younger than those with central ligament injury (mean age, 14.2 years) or periosteal (mean age, 14.2 years) avulsions ( P = .005). There was a significant association between the mechanism of injury and the location of UCL tear identified on MRI scans: traumatic falls were associated with distal tears, and throwing injuries were associated with proximal tears ( P < .001). Conclusion: UCL central ligament and avulsion lesions may be frequently diagnosed after injury to the pediatric medial elbow, the majority of which are complete injuries, and may require MRI for diagnosis. The mechanism of injury may predict the location of ligamentous injury, and osteocartilaginous avulsions are more likely to present at younger ages than injuries to the soft tissue of the UCL or periosteum. The prevalence of these injuries merits further investigation into best protocols of nonoperative treatment or surgical repair techniques and outcomes.

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Section: Discussionmentioning

confidence: 99%

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents

Sinha,

Wyatt,

Althoff

et al. 2024

Am J Sports Med

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“…Although nonoperative management of partial MUCL tears can result in a quicker RTP, treatment outcomes can be less predictable, especially among professional throwers, in whom RTP has been reported to be as low as 46% to 57%. 7,23 In contrast, UCLR can provide more reliable outcomes, with many studies suggesting RTP rates from 80% to 97%. 3,42 For high-level athletes, consideration must be given not only to initial cost of treatment, but also to longevity of their careers after treatment.…”

Section: Discussionmentioning

confidence: 99%

“…Many studies have evaluated biologic supplementation and its role in injury management. 7,12,23,37 In a case study of 34 amateur athletes with partial-thickness UCL tears who underwent PRP injections, Podesta et al 37 found at a mean follow-up of 70 weeks that 88% had returned to the same level of play with an 8-mm decrease in medial joint space opening with valgus stress as measured by ultrasound. In a similar study, Deal et al 12 found reconstitution of the MUCL via MRI after PRP injections in 23 of 25 amateur throwers after their RTP.…”

Section: Discussionmentioning

confidence: 99%

“…Nonoperative management must be carefully considered, especially among high-level athletes (ie, collegiate, professional, or those with collegiate and/or professional aspirations); however, it can be a valuable option, especially in throwers with partial tears. In a systematic review that included 365 amateur and professional throwers primarily with partial MUCL tears, Gopinatth et al 23 reported successful RTP in nearly 80% of athletes at 12 to 14 weeks. Among these patients, biologics such as platelet-rich plasma (PRP) are frequently added to supplement healing.…”

mentioning

confidence: 99%

“…Among these patients, biologics such as platelet-rich plasma (PRP) are frequently added to supplement healing. 12,23 Operative management is common for full-thickness tears and is commonly recommended in throwers with partial tears after failed nonoperative treatment. MUCL repair has been used with increasing frequency in recent years, and the duration of rehabilitation is often shorter when compared with reconstruction.…”

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confidence: 99%

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Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model–Based Analysis

Oeding,

Jurgensmeier,

Boos

et al. 2024

Am J Sports Med

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Background: Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. Purpose: To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional). Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors’ institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER). Results: The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. Conclusion: Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.

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Nonoperative Management of Medial Elbow Injuries in the Throwing Athlete

Super,

Mead,

Nussbaum

2024

Curr Phys Med Rehabil Rep

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Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis

Cited by 9 publications

References 47 publications

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents

Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents

Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model–Based Analysis

Nonoperative Management of Medial Elbow Injuries in the Throwing Athlete

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