Rare Elbow Injury in Older Baseball Players

Sports fans watch the clock closely that records how fast baseball pitchers throw the ball. The fastest pitch ever recorded in the Guinness Book of World Records is 100.9 miles per hour. Unofficially, some pitchers have been clocked at 103 to 104 miles per hours. But even in lower league play, those fastballs are moving 80 to 90 miles per hour and that puts a tremendous strain on the elbow.

The throwing motion repeated over and over can cause tiny tears in the soft tissues around the elbow -- especially the medial (inside edge of the) elbow. The first ligament to go is the ulnar collateral ligament (UCL). When that happens, the ability to throw becomes compromised by chronic, disabling elbow pain.

Older pitchers (30 years old or older) are at risk for damage to both the ulnar collateral ligament (UCL) and the flexor-pronator muscles. The flexor-pronator muscles bend the elbow and turn the palm down. The palm down motion needed to deliver the ball over the plate is called pronation is really a forearm motion that takes place at the elbow. In this study, hand surgeons from Harvard Medical School report on older baseball players with combined flexor-pronator and ulnar collateral ligament injuries.

These combined soft tissue injuries are rare but can keep a player out of the game -- permanently. Out of 187 male baseball players operated on by the author, only eight had the more extreme combined injury. All were major league baseball players (seven pitchers, one catcher). Of those eight, five had a poor result after surgery. Only one player reported an excellent outcome. The remaining two rated their results ss fair. Fair meant they were demoted from the major to minor league.

The likelihood of returning to sports play at the player's preinjury level after a combined flexor-pronator and ulnar collateral ligament injury is poor. Older age and chronic, degenerative changes affect soft tissue integrity and elbow joint stability. The authors suggest warning players with this type of injury that surgery may or may not help and the result may not be full return to the game.

Is age the only predictive factor in cases like these? That's one thing the surgeons wanted to find out because severity of injury (partial versus complete tear) could also make a difference. But then again, maybe age has something to do with how severely the soft tissues tear. And then there's also the chance that the type of surgery done could make a difference in the final results.

With these questions in mind, the data was analyzed. Type and extent of surgery was first assessed based on the patient's history, the surgeon's examination, and MRI results. The final diagnosis was made during the operation when the surgeon could get a first-hand look at the soft tissues in question.

Only one of the eight player was younger than 30 and he was 29 years old. The rest ranged from 30 to 42, so age was a big determining factor. Most of the injuries or tears were severe. One-third of the group ended up having at least one more surgery for re-tears of the repaired damage.

The authors concluded that older baseball players who already have damage to the ulnar collateral ligament from chronic repetitive throwing have a poor prognosis even with surgery. As long as the throwing speed is greater than the tensile strength of the soft tissues around the elbow, there's going to be a problem. Pain from tears and instability changes the way a player throws the ball.

Without full and unrestricted use of both the ulnar collateral ligament and the flexor-pronator muscle, successful return to play may be impossible for older pitchers. But there is good news in all this. Thanks to advanced imaging with MRIs, elbow injuries are recognized earlier now than they used to be -- early enough to prevent the more severe type of injuries suffered by the older players in this study.

The hope is that these combined injuries will be eliminated in today's young pitchers and catchers. Newer surgical and rehab techniques may also help improve final results. There's some indication that repeated cortisone injections may also be a risk factor for the combined injury. Since the combined injury is rare, it may take a while to see if these changes (early diagnosis and improved treatment) will eliminate this type of injury.

References: Daryl C. Osbahr, MD, et al. Combined Flexor-Pronator Mass and Ulnar Collateral Ligament Injuries in the Elbows of Older Baseball Players. In The American Journal of Sports Medicine. April 2010. Vol. 38. No. 4. Pp. 733-739.