Orthopaedics and Rehab

UCL injuries on the rise, from Little League to the major leagues

Orthopaedics and Rehab

Young boy pitching a baseball
Throwing injuries in the elbow are rising as more young athletes specialize in one sport year-round.

As professional athletes continue to stretch the limits ­of what’s possible with 100 mph fastballs and 70-yard touchdown passes, the next generation is desperately trying to keep up with sports heroes like Jacob deGrom and Patrick Mahomes.

One joint bears a heavy load in this chase for greatness: The small but mighty elbow.

With baseball and softball seasons getting underway, we are likely to see a fresh wave of elbow injuries from Little Leaguers to the major leagues.

One particularly painful elbow injury that's on the rise is the torn or ruptured ulnar collateral ligament. The UCL is a collection of three bands that connects the humerus bone (upper arm) to the ulna (the larger of the two forearm bones) and runs along the inside of your elbow. The biomechanics of throwing puts the UCL under extreme stress and cumulative microtraumas from the repetitive motion can weaken the ligament over time, causing painful sprains, strains, and tears.

UCL injuries can also happen suddenly, as football fans saw in the 2023 NFC Championship game between the San Francisco 49ers and the Philadelphia Eagles. Rookie 49ers quarterback Brock Purdy was sacked by Eagles linebacker Haason Reddick, who hit his elbow and halted the forward momentum of the QB’s throwing arm, causing his right UCL to rupture. Purdy was scheduled for UCL repair or reconstruction surgery in March 2023 and is expected to be sidelined at least six months.

Collegiate and professional sports programs are starting to take more precautions against UCL injuries, but they’re on the rise in youth and high school sports. This is due in part to increased competitiveness and the trend of young athletes playing one sport and one position year-round.

How sports specialization contributes to injury

For parents of young athletes with big dreams, it’s worth noting that there is no empirical evidence showing early sport specialization enhances performance or increases a player’s chances of succeeding at an elite level.

Research actually shows the opposite – 91% of first-round NFL draft picks were multisport athletes in high school, and Olympians participated in an average of three sports a year until age 14.

A recent study found that about 27% of 845 elite high school pitchers who threw in showcase events for scouts went on to have reconstructive UCL surgery.

To reduce UCL injuries, Major League Baseball and USA Baseball conduct a “Pitch Smart” program, which sets age-appropriate guidelines for players, coaches, and parents, recommending rest periods between games and limiting the number of pitches players can throw. For example, a young pitcher should not throw more than four times their age in pitches per game – no more than 60 for a 15-year-old.

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While UCL injuries rarely affect the ability to do normal activities like chores or going to school, they can make throwing or even gripping a ball difficult, if not impossible, without treatment. Symptoms of a UCL injury can include:

  • Popping sensation on the inside of the elbow
  • Pain while throwing but not during normal activities
  • Numbness and tingling in the ring and pinky fingers
  • Swelling or irritation on the inside of the elbow

Don’t put off getting these symptoms checked by an orthopedic or sports medicine doctor. Complications such as nerve damage and stress fractures can result from untreated injuries.

In diagnosing a UCL injury, the doctor will perform a physical exam before ordering imaging such as an X-ray or MRI to help determine the extent of the injury. From there, we will recommend treatment based on the severity of the injury and the athlete’s goals for returning to competitive play.

Related reading: Kids and sports: How specialization can lead to overuse injuries

Treatment options for UCL injuries

Non-surgical treatments are the first choice for sprains or minor partial UCL tears. These include rest, anti-inflammatory medications, ice, and physical therapy to rebuild strength and increase range of motion.

After about eight weeks, athletes can slowly resume throwing practice. To return to play, athletes should be able to demonstrate full, pain-free range of motion and strength, as well as proper throwing mechanics for their sport. The rehab process can take 12 weeks or longer.

Elite athletes who want to return to top-level competition after a torn UCL may choose repair or reconstruction surgery. However, having elbow surgery can decrease the chances of making it to the next highest level of play. About 10% of pitchers who have reconstructive UCL surgery do not return to their pre-injury performance level. For minor league pitchers, the chances of making it the major league decrease by 50%.

UCL repair surgery can treat certain ligament tears. Through a small incision on the inside edge of the elbow, the surgeon places anchors in the bones that allow stitches to support the ligament and repair the damaged tissue. Patients usually leave the hospital the same day in a sling that can be removed after a week. In about 10 weeks, patients can usually begin a supervised throwing program with the goal of returning to competition about six months after this elbow surgery.

Almost 97% of athletes can return to throwing following the repair procedure. In youth athletes, results rated “good to excellent” were noted in a study of UCL repairs, and 58 of 60 patients were able to play at the same or a higher level when they returned to competition.

UCL reconstruction surgery, also called Tommy John surgery after the Los Angeles Dodgers pitcher who first received this surgery in 1974 from Frank Jobe, M.D., involves rebuilding the ligament when overuse has worn away too much of the original UCL to repair it. Nearly 57% of UCL reconstructions in the U.S. are in 15- to 19-year-olds – and the number of surgeries are increasing 9% per year.

The surgeon makes an incision in the elbow and creates tunnels through the ulna and humerus bones. Then we transplant a healthy tendon, usually from the patient’s wrist, to restore support to the elbow.

Recovering from UCL reconstruction can take nine months to a year. About 90% of patients who undergo Tommy John surgery can return to competition at their preinjury level of activity. Multiple MLB pitchers, including the two-time Cy Young winner deGrom, who signed with the Texas Rangers in December 2022, have successfully returned to the mound after UCL reconstruction.

Related reading: High school athletes' most common injuries – and how to avoid them

Tips to prevent UCL injury

While we can achieve remarkable results with UCL repair and reconstruction surgeries, prevention is key – especially for student athletes. Precautions to prevent a UCL injury include:

  • Stretching and warming up before physical activity
  • Slowly increasing pitch force and velocity while warming up
  • Using proper technique and mechanics
  • Avoiding throwing when your arm is sore
  • Applying ice on the elbow after pitching to prevent inflammation
  • Following pitch-count and rest recommendations from coaches, trainers, and the sport’s governing program

Without treatment, a UCL injury can be devastating. If you or your child have trouble throwing or feel pain inside the elbow, talk with a sports medicine or orthopedic doctor about your treatment options. With timely and specialized care, you can safely get back to the sport you love.

To find out whether you or a loved one might benefit from an elbow exam, call 214-645-8300 or request an appointment online.