The Role of Early UCL Reconstruction
Throwing a baseball puts a large strain on the medial ulnar collateral ligament of the elbow. This ligament is located on the inside of the elbow and injury can be acute, with players feeling a “pop”, or more gradual with months of elbow pain. Injuries to the ligament can be a full tear, where all of the fibers are torn across, or a partial tear where some fibers do remain. An article published in the American Journal of Sports Medicine looked at the financial implications of performing early surgery for partial tears verse conservative treatment which could include injection and physical therapy.
Partial tears are difficult to treat because they can become full tears or continue to cause pain and not heal but remain partially torn. It is important to be cautious when evaluating these studies because in this case they used a Monte Carlo Microstimulation (1), which is a predictive model they created to generate estimates on cost. This study did argue that it is cost effective to perform a medial ulnar collateral ligament reconstruction in high level pitchers compared to nonoperative management (1).
I do not think that we should extrapolate this data so that every pitcher with a partial UCL tear should be referred for surgery. Platelet rich plasma injections into the UCL show promise as a nonsurgical treatment. We are still learning the appropriate number of injections needed and amount of platelets needed to standardize these treatment protocols.
It is also important to note that studies have been performed looking at the percentage of pitchers who return to their previous level of performance after a UCL reconstruction. Data has shown that 79% to 92% of pitchers can return to preinjury level (2). This is important, because if we performed surgery on a patient as a cost savings measure and they never return to their previous level of performance, than we are not doing what is in the best interest of the patient. Another consideration is that recovery from reconstruction can take approximately one year (2). Nonsurgical treatment does have the potential to have the pitcher return to play faster (2).
References
1) Oeding, Jacob F., et al. “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.” The American Journal of Sports Medicine, June 2024, p. 3635465241255147. PubMed, https://doi.org/10.1177/03635465241255147.
2) Coughlin, Ryan P., et al. “Return to Play and In-Game Performance Statistics Among Pitchers After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review.” The American Journal of Sports Medicine, vol. 47, no. 8, July 2019, pp. 2003–10. PubMed, https://doi.org/10.1177/0363546518798768.