UVA Health orthopedic surgeons Bobby Chhabra, MD, and Rashard Dacus, MD, are experts in treating an injury that’s becoming more common in even young athletes — so common some consider it an epidemic.
Chhabra and Dacus specialize in hand and upper extremity injuries, and have close to 40 years of experience between them in treating elbow ulnar collateral ligament (UCL) injuries in overhead-throwing athletes, including UCL reconstruction surgery. UCL injuries most commonly affect pitchers and other baseball players — from Little League all the way up to MLB — and surgery is increasingly indicated for athletes at younger ages.
“These injuries are becoming more and more common because of the culture of baseball in this country where pitchers basically pitch year-round,” Chhabra says. “There also aren’t many surgeons who perform these operations because there’s a lot of expectations from parents, coaches, and the players themselves. But we’ve been taking care of these athletes for years and have the highest level of expertise in the state and region.”
Why UCL Injuries Occur
When a thrower fatigues and drops their shoulder during a pitch — subjecting the medial elbow to repeated high-speed valgus torque — the UCL is at risk for injury or tear. UCL injury is a particular risk for baseball pitchers, who are increasingly challenged to throw harder, faster, and more frequently at increasingly younger ages.
“It’s, unfortunately, become somewhat of a rite of passage for throwing athletes now,” Dacus says. “Some of this is related to pitchers throwing more and more at earlier ages, as well as a lack of diversifying sports and year-round throwing.”
Chhabra and Dacus see UCL injuries most often at the end of the fall and spring seasons. “The pitchers are fatigued and their mechanics suffer,” says Chhabra, who serves as the University of Virginia Athletics team physician for hand and upper extremity injuries.
MLB and USA Baseball started a program to reduce UCL injuries called Pitch Smart, which sets age-appropriate guidelines for players, coaches, and parents, including recommendations for rest periods between games and limits on the number of pitches players can throw. Yet injuries remain on the rise across youth, collegiate, and professional athletes.
The Impact of UCL Injuries on High-Level Throwers
Elbow injuries account for 16% of all injuries sustained by college and professional baseball players, according to the Arthroscopy Association of North America (AANA). Each injury in a professional player costs MLB close to $2 million. Each player who undergoes UCL reconstruction surgery, or “Tommy John surgery,” is out for an average of 17 months.
Not every UCL injury needs to be treated with surgery, but it’s currently the first-line treatment for promising athletes who want to get back to the same level of performance they were at before their injury. That’s the expectation from the parents, player, coaches, and trainers, Chhabra says — that they’ll return better and stronger. While that’s not always the case with UCL reconstruction surgery, it is true most of the time.
“That’s why we do this operation,” Chhabra says. “It was designed to allow a high-level baseball pitcher with high-level aspirations to keep pitching.”
Chhabra adds: “For a non-thrower, like a football player or wrestler, if they have a UCL injury — and they get them frequently — they don’t need surgery and will heal with conservative treatment.”
Still, a very small percentage of players go on to the next level of baseball, says Dacus, who serves as the James Madison University Athletics team physician for hand and upper extremity injuries. “It’s important to have that conversation with parents and set realistic expectations,” he says. Sometimes it’s protecting the player from themselves. “Everyone wants to play, and they won’t tell you they’re having pain if it means they can keep playing, so we have to try our best to protect the athletes,” he adds.
A Long Rehabilitation Process
Throwing athletes who present with any medial elbow pain need to be evaluated for UCL injury, Chhabra says. Some of the time, they describe hearing a pop when the injury occurred, but they frequently don’t. They also may have some swelling and ecchymosis, but that’s fairly rare. Most of the time, they feel some pain and continue to pitch, but nearly all notice a loss of velocity and control.
If diagnostics indicate a partial UCL tear, it’s considered a sprain. If it’s a first-time injury and it’s a partial or low-grade tear, it can often be treated nonsurgically, with no throwing for three months and a brace to protect against valgus stress. Still, rehabilitation needs to include a graduated return to throwing.
In patients with complete, acute ruptures, high-grade tears, or failure to progress with pitching after three months of conservative management, surgery is typically indicated, which generally involves recreating the ligament using a tendon graft. Often, Chhabra says, surgery is the easiest part of the process.
Rehabilitation is lengthy and includes immobilization of the elbow for roughly two weeks, followed by easing into elbow and shoulder range of motion, often with a brace. Strengthening can be introduced at 4 to 6 weeks, but there can’t be any valgus stress until 4 months. At 7 months, the patient can start a graduated program of range of motion, total body conditioning, and 50% throwing effort. At 9 months, they can throw at 70% maximum velocity. If they have no pain and a full range of motion, they can begin throwing competitively again after one year. 18 months is when they can return to their previous level of play, but they should be carefully supervised by trainers who understand the protocols for UCL rehabilitation.
“When pitchers tell me they feel great 4 or 5 months after surgery and are ready to start throwing again, I tell them you can’t rush biology,” Chhabra says. “It takes time for the tendon graft to strengthen to that of a ligament and give you the support you need to throw again.”
He adds: “The worst thing that can happen is for someone to return to throwing early and re-rupture the reconstruction, because the likelihood of returning to throwing at the same level with a recurrent UCL injury is very low.”
Today, after a first time injury and reconstruction return to previous level of performance after 18 months is, on average, up to 97% — a stark increase from the 1970s, when the percentage was 63%.
Still, reaching an optimal return to performance requires specialized expertise.
At UVA Health, “there are 2 of us who take care of these injuries,” Dacus says, “so you’re able to get differences of opinion, which I think is helpful because every athlete is different. We take care of all age groups, from young kids to collegiate athletes to post-college, so we see the spectrum, which also gives us a different perspective on treatment options. And we have therapy in-house, so we’re able to establish the proper therapeutic regimen. We also have athletic trainers in our clinic, so they’re able to help facilitate the training portion pre- and post-operatively.”
Tapping New Treatment Options
Although the gold standard for treating UCL injuries has been reconstruction, thanks to improved outcomes and new technologies, some surgeons, including Chhabra and Dacus, have been incorporating UCL repair with ligament augmentation in recent years.
“We’re doing internal bracing and repairing the ligaments with the goal that this approach result in a shorter recovery,” Chhabra says. “It’s been an advance in terms of thinking we can repair and augment a native ligament instead of using a graft to reconstruct because grafting has a longer recovery. Currently there are studies investigating repair over reconstruction in high level throwers and this may give us more information."
In addition to different techniques, Chhabra and Dacus are also looking at different biologics that could be used to improve healing, such as collagen tape for acute repairs and platelet-rich plasma (PRP) injections in partial ligament injuries to try to avoid surgery.
“We offer a lot of different treatment options for patients, depending on their needs,” Dacus says. “Sometimes it’s a nerve problem, sometimes it’s a repair and bracing, sometimes it’s a full reconstruction. We tailor the treatment to the patient in each and every case.”