Introduction
While there is abundant literature on ulnar collateral ligament (UCL) injuries in male athletes, predominantly professional baseball players, research remains sparse on the pathoanatomy, epidemiology, treatment, and outcomes of UCL injuries in female athletes. A literature review by Gardner and Bedi demonstrated that only 79 of 1902 (4.15%) patients within UCL studies are female. The majority of elbow UCL studies consist of either small case reports or limited case series or otherwise involve larger studies where a predominant cohort of the athletes are male. A small subset of these larger studies includes female athletes; however, many of the studies do not separate out the female athlete when specifically discussing outcomes.
Several recent studies have highlighted gender-related differences in orthopedic conditions; however, there remains a paucity of literature on outcomes following the treatment of UCL injuries in female athletes. The majority of studies on elbow UCL injuries focus on professional baseball pitchers. Baseball is a sport dominated by male athletes, whereas softball is dominated by female athletes. Softball pitchers have a significantly different throwing pattern (underhand/windmill) than baseball pitchers (overhand), which may protect them from UCL injuries.
Electromyographic study of the windmill pitch demonstrates that the highest level of biceps eccentric contraction occurs at the 9 o’clock position, just prior to ball release when the shoulder is experiencing maximum distraction stress and the elbow is experiencing maximum extension torque. Peak biceps motor activation was significantly higher than that during an overhand throwing motion where the biceps is responsible for providing elbow flexion torque. Alteration of peak forces with the elbow flexed (overhand) versus extended (underhand/windmill) may be related to the incidence of UCL injury. When standard overhand throwing kinematics and kinetics are compared between genders, females were found to have lower ball velocity, lower elbow extension angular velocity, lower proximal forces on the elbow and shoulder joints, lower pelvis and upper torso rotation, and shorter stride length. Notably, in this study, these reductions were not compared to the overall athlete stature or body muscle composition, but rather were compared as absolute values.
Gymnastics represents a more female-dominated sport (compared with male athlete participation). Elbow UCL injuries tend to occur from the overhead, weight-bearing/compression, and the rotational forces on the upper extremity caused by the unique movements of the sport. Therefore gymnasts represent a large proportion of female athletes with UCL injuries. Floor exercises followed by balance beam have been shown to have the highest rates of acute injuries, with bars and vault having lower injury rates. Large lateral compression and valgus forces have been noted during the double-arm support phase of a backhand spring (a maneuver performed on both floor and balance beam), which may explain the pathogenesis of lateral capitellar osteochondritis dissecans (OCD) and UCL injuries during this maneuver.
Nonoperative Management of Ulnar Collateral Ligament Injuries in Female Athletes
Nonoperative management of UCL injuries consists of a combination of rest, use of nonsteroidal antiinflammatory medications, immobilization with casting or bracing, and rehabilitation exercises. Rehabilitation programs progress through phases with the initial goal of reducing pain and maintaining or restoring full range of motion. , Athletes then focus on periscapular and rotator cuff strengthening with the goal of regaining strength at or above baseline. An interval throwing program can then be initiated, provided athletes are pain-free. , Throwing athletes generate increased forces at the elbow when utilizing an effort-based return to the throwing program; therefore a relative velocity return to the throwing approach may be more successful. Modalities that may be used in conjunction with therapy include soft tissue mobilization, electric stimulation, ultrasound, and laser therapy. In some cases, injections with platelet-rich plasma (PRP) can be performed.
Nonoperative treatment of UCL insufficiency has been most commonly evaluated among throwing athletes, with return to play being the primary outcome variable. Ford et al. reported 84% return to the same level of play in 31 professional baseball players with partial UCL injury diagnosed by magnetic resonance imaging (MRI), with 3 athletes failing rehabilitation and going on to have surgery. The authors concluded that rehabilitation was a viable option for treating partial UCL injuries, even among professional baseball players. Conversely, in a series of baseball players with an average age of 18 years, only 42% of the athletes were able to return to their previous level of participation following a minimum of 3 months of rest along, with rehabilitation exercises. Diagnosis of UCL insufficiency or tear was made by physical examination findings of tenderness over the anterior band of the UCL and pain with both the milking maneuver and valgus stress in all patients. All patients had radiographs taken of the affected elbow; some had stress radiographs comparing the involved side to the asymptomatic elbow and some had MRI to confirm the diagnosis. Athletes who were able to return to the same level of play following nonoperative treatment did so about 6 months following diagnosis, and no factors could be identified to predict the success of nonoperative treatment.
The efficacy of nonoperative treatment of UCL injuries among female athletes is not well understood. Nicolette and Gravlee presented a series of five Division I collegiate gymnasts who sustained acute UCL injuries from a valgus load to the elbow. Among the five athletes, four (80%) were able to return to basic gymnastic skills between 1.5 and 12 weeks following a structured rehabilitation program. In gymnastics, athletes can return to one, some, or all events, which may speed up recovery time by selecting an event that least precipitates symptoms. Although this is a series of only five athletes, it does suggest that for an acute injury in a nonthrowing athlete, nonoperative treatment can be successful.
More recently, PRP has been used as an adjunct to rest and rehabilitation in the nonoperative treatment of UCL injuries. , Podesta et al. utilized PRP injection as a supplement to rehabilitation for the treatment of MRI-confirmed partial UCL tears in a cohort of 35 athletes (28 males and 6 females consisting of 27 baseball players, 3 softball players, 2 tennis players, and 2 volleyball players; mean age of 18 years). Following a single PRP injection, 88% of athletes had successfully returned to play at an average of 12 weeks. The PRP injections were administered for continued symptoms following a minimum of 2 months of rehabilitation. Deal et al. treated 25 adolescent and young adult throwing athletes with MRI-diagnosed partial UCL injuries using a combination of a varus loading hinged elbow brace, rehabilitation, and two sequential ultrasound-guided PRP injections spaced 2 weeks apart. Only two of these athletes were female, both of whom played softball. Following the two PRP injections, 96% of the athletes with a primary injury were able to return to play at the same level or a higher level and had stable elbows on ultrasound evaluation. In the athletes who were able to return to their sport, all but two showed healing of the UCL on posttreatment MRI. The only complication reported among athletes receiving PRP injections was localized swelling that resolved over 24 h.
With studies showing mixed results for nonoperative treatment of UCL injuries, some authors have tried to identify factors that may predict an individual’s response to conservative management. , Among the professional baseball pitchers who failed nonoperative management, 82% had a distal UCL tear on MRI, whereas among those who were able to return to pitching following rehabilitation alone, 81% had proximal tears. Currently, no study has evaluated UCL tear location in female athletes or nonprofessional athletes as a predictor of successful nonoperative management.
Not only the location of the UCL injury but also the extent of injury seem to be important in predicting the need for surgery. MRI staging (or grading) has been proposed, with four injury grades: grade I injuries involve an intact ligament with or without edema, grade IIA includes partial injuries, grade IIB represents chronic healed injuries as indicated by ligament thickening without tearing, and grade III injuries involve a complete tear of the UCL. , A study of professional baseball pitchers treated nonoperatively showed that the rate of return to play was 100%, 83%, and 94% for grade I, grade IIA, and grade IIB injuries, respectively. Using a different MRI grading scale, Kim et al. similarly reported intact continuity of the ligament and low-grade partial tears more commonly in baseball players who were managed with rehabilitation alone, whereas high-grade partial tears and complete ruptures were more common in those requiring surgical intervention. So far, no study has evaluated the UCL tear grade in female athletes or nonprofessional athletes as a predictor of successful nonoperative management.
Operative Management of Ulnar Collateral Ligament Injuries in Female Athletes
There is currently limited data on the operative management of UCL injuries in female athletes. , , While specific indications for acute repair or reconstruction are unclear, failure of sufficient nonoperative management is an indication for surgical intervention.
Case series, including those evaluating outcomes following operative management of UCL injuries in female gymnasts, have limited follow-up and lack detailed outcome measures. Nicolette et al. reported on five female Division I collegiate gymnasts with UCL injuries; however, only one patient underwent surgery: a 19-year-old female gymnast who sustained a valgus load to the elbow resulting in a distal UCL tear with “complete tear at the insertion of the anterior band of the UCL off the sublime tubercle,” as demonstrated on magnetic resonance arthrogram of the elbow. After a thorough nonoperative rehabilitation program, the patient underwent UCL reconstruction because continued pain and instability limited her participation in gymnastics. Postoperatively, she began light tumbling at 5 months and was cleared for full participation 6 months after surgery. Grumet et al. published an isolated case report on a 16-year-old female high-school gymnast who was found to have a bony avulsion of her sublime tubercle, which contained the anterior band of her UCL. The patient underwent open repair of her bony avulsion using two suture anchors because of persistent elbow instability with valgus stress. Postoperatively, the injury was splinted for 2 weeks that was then converted to a hinged elbow brace set 30–105 degrees. At 2 month after repair, a strengthening program was initiated. At her final postoperative follow-up (6 months), the patient had full elbow range of motion, no tenderness to palpation, and her elbow was stable to valgus stress. The patient noted pain (1/10) with “heavy lifting or repeated elbow movements,” yet had returned to full competition at her preinjury level. Final radiographs at 1 year did not show any degenerative joint changes.
A large cohort study by Cain Jr et al. was performed to evaluate the results of UCL reconstruction at a minimum of 2-year follow-up in an athletic population. This population of athletes primarily involved baseball players (95%); however, it also included football, javelin, softball, tennis, wrestling, soccer, gymnastics, cheerleading, and pole vaulting athletes. This study highlights the rarity of UCL surgery in female athletes: only 28 of 1281 (2.2%) patients were female. A majority of the patients in this study underwent reconstruction (1266 patients, 98.8%) versus repair (15 patients, 1.2%). Indications for UCL reconstruction included failure to progress through a rehabilitation program after 3 months. Reconstruction involved the use of autograft palmaris longus, gracilis, or plantaris, along with concomitant subcutaneous ulnar nerve transposition using a modification of the original Jobe technique. Although 2-year outcomes were reported, they were not separated by gender. About 83% of athletes with reconstructions and 70% of those with UCL repair returned to the same or higher level of sport. The average time from surgery to throwing was 4.4 months, and the average time for return to full competition was 11.6 months. Complications with operative treatment were reported in 20% of cases, with the most common being a minor postoperative ulnar nerve neuropraxia, which involved only sensory changes and was resolved by 6 weeks. A total of 55 patients underwent subsequent elbow surgery between 6 and 7 months after the initial reconstruction (1% required revision UCL reconstruction). Without gender as an independent variable, it is difficult to make any gender-specific conclusions about UCL reconstruction or repair from this study.
Only two available studies report on young athletes with UCL injuries. Savoie et al. reported on primary repairs of the UCL in elbows of young athletes with age ranging from 14.8 to 22 years (mean, 17.2 years) and 13 of 60 (21.67%) athletes included were female. Nonoperative treatment was attempted for an average of 4.1 months before proceeding with repair. This study found that 56 of 60 (93%) athletes were able to return to sports within 6 months with good to excellent functional results. In this study, four patients had failures according to the functional results and the Andrews-Carson rating scale. None of the four patients were female athletes.
Jones et al. reported on the docking technique of UCL reconstruction in adolescent athletes and 4 of 55 (7.27%) athletes included were female. While they did not give the specific breakdown by sport, three gymnasts and five javelin throwers were included in addition to the majority cohort of baseball players ( n = 47). Overall, 87% of athletes reported excellent results using the Conway scale ( Table 18.1 ). However, two of three (66%) female gymnasts (average age, 15 years) had poor outcomes according to the Conway scale. Both of these female athletes had OCD lesions of the capitellum, in addition to their UCL injuries, complicating interpretation of the results. Additionally, two gymnasts and two javelin throwers had postoperative complications of a transient ulnar neuritis after UCL reconstruction; however, the gender of these patients is unknown.
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