Adolescents Return to Play at High Rates after UCL Reconstruction

Hadley CJ, Edelman D, Arevalo A, Patel N, Ciccotti MG, Dodson CC. Ulnar collateral ligament reconstruction in adolescents: A systematic review. Am J Sports Med. 2020:1-8. doi:10.1177/0363546520934778

Ulnar collateral ligament injuries are on the rise in adolescent baseball players.  Contributing factors are believed to be related to excessive amounts of competition, increasing fastball velocity, inadequate warm-up, geographic location, and glenohumeral internal rotation deficit.  The greatest surge in UCL reconstruction surgeries has occurred in those 15 to 19 years old. 

Purpose

The purpose of this systematic review was to evaluate return-to-play (RTP) rates and subjective outcome scores of UCL reconstruction of the elbow in adolescent throwing athletes.

Study Methods

The inclusion for all primary studies included:

  1. UCL reconstruction of the elbow in adolescent athletes (10-19 years old) with an injury occurring in an overhead throwing sport
  2. Outcomes assessed the athlete’s ability to return to pre-injury level of sports participation, with an evidence level of 1 to 4.

Articles were excluded from the analysis when adolescent athletes were mentioned but their data could not be directly determined.

Key Results

Nine retrospective case series with a total of 414 athletes were included.  The majority of athletes (97.6%) were baseball players and participating at the high school level (85.3%).  Athlete mean age was 18.1 years.

Of the 414 patients included, 349 were able to RTP at their pre-injury level or higher, resulting in an RTPP rate of 84.3%.  Thirty-four patients returned at a lower level of competition.  And 26 patients (6.28%) did not return to play.

Common reasons for not achieving RTPP included experiencing continued elbow pain (12 athletes), fear of re-injury (2 athletes), re-injury (2 athletes), personal reasons (7 athletes), and the presence of other medical conditions (2 athletes).

Complications of surgery were rare (3.9%).  This included fracture of the medial epicondyle (2 athletes), heterotopic ossification and arthrofibrosis (1 athlete), and excision of calcium deposits (1 athlete). Also, 7 athletes reported ulnar nerve symptoms/complications.

Return to Play Rates after UCL Reconstruction is Similar in Adolescents and Adults

This systematic review found 84.3% of adolescent athletes successfully returned to their pre-injury level or higher (RTPP) and 92.5% were able to RTP at some level.  These RTP proportions are consistent with those reported in other systematic reviews investigating baseball players across various age ranges1.

With RTP proportions at 80% to 90% or higher, we can confidently say that UCL reconstruction is a viable treatment option for adolescent athletes looking to continue their playing career. However, UCL repair is another surgical treatment option that has recently gained interest. This is due to a better understanding of UCL pathology, improved fixation techniques, and the extensive rehabilitation required to RTP following UCL reconstruction. 

Repair is recommended when the tear is located at the proximal or the distal insertion sites. Repair is considered less effective with attritional or degenerative injuries to the mid-substance of UCL.   With effective patient selection, adolescent athletes can return to competitive play as early as 6 months after UCL repair vs. the typical 12 to 18 months following UCL reconstruction.

Despite a dearth of evidence related to conservative treatment in adolescents with UCL injury, a trial of non-operative management is usually indicated.  In this systematic review, the mean duration of symptoms prior to UCL reconstruction was 7.2 months.  Therefore, 3 to 9 months of conservative treatment (based on the time of season, etc.) may be a wise first line approach.

References

  1. Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP. The success of return to sport after ulnar collateral ligament injury in baseball: A systematic review and meta-analysis. J Shoulder Elb Surg. 2018;27(3):561-571. doi:10.1016/j.jse.2017.12.003

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