Thank you very much. Thanks to Anna and Scott Steinman for inviting me to participate in this scientific session. I want to talk to you this morning about how partial UCL tears are treated best non-operatively sometimes. And it all depends on the indications. I have no financial disclosures, but I do need to let you know that I do perform surgery for some partial UCL tears and the discussion would be on which ones. So if we talk about the UCL disease burden, 25% of major league baseball pitchers have had UCL reconstruction performed while as a pro athlete. 15% of minor league pitchers have had UCL reconstruction. The majority in high school or in college. And this is from an ESPN segment that showed that in major league baseball in the year 2014, there were more Tommy John surgeries performed in that one year than the entire decade of the 1990s. This is a graphic representation that demonstrates the logarithmic growth of the number of Tommy John surgeries performed. But for the majority of us, we may take care of some high-level athletes, but we'll be taking care of many adolescent athletes and collegiate athletes. So what is the disease burden among adolescents and the patient population that many of us see? This is from a study that Brandon Erickson had done with Tony Romeo, Pearl Diver Computer Database search for the code for MUCL reconstruction yielded 790 cases. The average annual incidence was slightly less than four per 100,000 people. But in the adolescent group from 15 to 19, there were 22 surgeries performed in that same 100,000 cohort. The other interesting observation is that the incidence of Tommy John surgery performed in that age group increased by 9.2% annually. And in fact, more than half of all cases performed were in that age group. So there's some provocative articles as well as discussions that are being raised across the country about early specialization as well as overuse, and that the definitions of what we do in suburban America in baseball nowadays may be considered overuse. So here's some of the contributing factors. This is at a high school game. And for a prospect, they're just trying to throw as hard as they can. So for some of these youngsters, for anyone, but especially the youngsters, what's the effect of the long recovery associated with surgery? Really of any type, not specifically UCL, but specifically for baseball. There's a financial burden in professional baseball for both the athlete and for the club. There are concerns about playing time as well as scholarships and NCAA eligibility. And then there's also a mental and psychological burden. There's uncertainty, doubt, fear, anger, resentment, depression, anxiety, difficulty coping that may lead to self-medication. And especially concerning in the adolescent population is how would those less mature individuals cope with a potential immature coping skill set that they may have? This is a paper that we published in CORE last year where we looked at upper extremity injuries among baseball players and looked at the patient's self-reported rate of depression and coping skills and thoughts of catastrophizing and asked their parents as a dyad to predict, not predict, but to comment on their own perceptions. And the parents overestimated the amount of depression but underestimated their children's ability to cope and also their children's severity with regard to catastrophizing their condition. So how can we help the entire athlete? When we're talking about avoiding surgery or treating conditions non-operatively, it's not just for a podium presentation or a healthy debate, but it's important to identify partial tears in the throwing athlete that may respond to non-op treatment to potentially reduce time away from their sport and also for their overall physical and mental wellness. So which partial tears are amenable to non-op treatment? What are important in decision making? This talk is limited to baseball, but depending on the sport, there may be different considerations. Perhaps the partial tears are more amenable to non-operative treatment in younger athletes. We need to talk about the desired level of competition. Timing matters. If you have an NCAA athlete and you initiate non-op treatment and ultimately they fail and need to convert to a surgical cohort, we need to make sure that they won't lose two NCAA eligibility years. Tissue quality matters. There's a location of the tear matter. How about acute on chronic versus chronic as well as concomitant injuries? So what is a partial tear? And there's a spectrum of ligament injury. There could be injury in continuity, there could be partial tears both at the proximal or distal sites or in the mid substance, and there's a full tear. So we're not discussing full tears in this specific talk, but let's talk about some of the others. So the MRI classification can help us to sort out some of the different severity of partial tears. Type 1, 2, 3, 4, low grade, high grade, complete tear, as well as tear in multiple locations. And that has some implications on deciding if you're going to perform surgery whether you do a repair versus a reconstruction, and we'll have some speakers afterwards speaking about that. Similar to studies performed in the baseball player's shoulder, when you take an MRI of an asymptomatic throwing athlete's elbow, there are going to be abnormal findings. This is a study that looked at 23 asymptomatic male high school baseball pitchers with no history of previous elbow injury. They reported a minimum of three years pitching as a primary position. The mean was six years. There were bilateral MRIs done on both elbows and read by a blind musculoskeletal radiologist, including hand dominance. So only 13% had a completely normal MRI. 65% of them had an abnormality of the anterior bundle of the ulnar collateral ligament. 61% had either sclerosis or osteophyte formation, and 43% had multiple abnormal findings. In this study, there were 43 UCL tears evaluated for return to play as well as return to the same level of play. The MRI were graded, and for those who had complete tears, eight of them, all underwent reconstruction with a 75% return to play and 63% return to the same level of play. Among the 35 incomplete tears, seven ultimately ended up having a UCL reconstruction with a fairly high return to play and return to same level. Interestingly, 28 out of the 35 who were treated nonoperatively had a surprisingly good outcome, 93% for both return to play and return to same level of play. So that tells us that nonoperative treatment is viable and is an important consideration. In this study by Mark Schickendance, there was a retrospective cohort study performed with the Indians from 2006 to 2015. 32 pitchers underwent initial nonoperative treatment for a UCL injury. Eleven of them failed, which means 34% required subsequent reconstruction. Twenty-one out of 32, so two-thirds of that cohort returned to the same level of play for one year without surgery. And there was no significant difference at that time in physical exam findings or performance metrics between those groups. Interestingly, they observed some findings on the MRI that were instructive. Eighty-two percent who failed non-op treatment and needed surgery had a distal tear. Eighty-one percent who were able to return to the same level of play had a proximal tear. So when adjusting for age, location, and evidence of chronic changes on the MRI, there was a likelihood of failing non-op treatment with a distal tear that was 12.4 times greater. So are there some other considerations other than just MRI observations? Is there a biomechanical reason for that? And Mark looked at some cadavers. He had an eight intact cadaver and applied different types of torques after sectioning the ligament, and the sectioning of the posterior and distal ligament had the greatest instability. And so he was able to observe that proximal tears may be more amenable biomechanically to non-operative treatment. So what is non-op treatment? There's really no consensus for the optimal program, and most are based on surgeon preference, and the results are not well reported, and it's quite variable, and they're the role of biologics which are discussed. There's a multidisciplinary approach, generally, for the physical therapy rehab component of non-op treatment. You continue cardio, core, and lower extremity modalities. You do upper extremity strengthening. You work on the entire kinetic chain, which is important, and you proceed with batting and an interval program. With PRP, there have been different studies. Thirty-four MRI documented cases of partial tears that failed two months of non-op treatment. After a single ultrasound-guided injection of PRP and PT, 88% were able to return to their same level of play at 12 weeks on average. This is another study, 44 partial tears with variable number of PRP injections, and 73% had an excellent good outcome with a mean time to throw and return to play that is relatively shorter than any surgical treatment. So in summary, UCL injury affects athletes both physically and mentally. Non-op treatment should be sought for the general wellness and benefit of the entire whole athlete. There are many factors to consider for surgical versus non-op treatment, and it depends on the appropriate indications. Non-op treatment should be considered particularly for proximal UCL injury in the younger athlete without concomitant injuries. And this area is ripe for a multi-center research study, so stay tuned. Thank you very much.

partial UCL tears

UCL reconstruction surgeries

adolescent athletes

non-operative treatment

proximal UCL injuries