José De León, 25 years old, was diagnosed with a torn medial collateral ligament (MCL) in his right elbow this spring. Throwing athletes (baseball pitchers and javelin throwers) can develop a looseness in the MCL after years of repeatedly throwing as hard as possible. In baseball, a single fastball creates enough force to completely tear the MCL, but the stabilizing force of the muscles prevents this. The theory is that repeated small sprains (ligament tears) outpace the body’s healing capacity leading to thinning of the MCL. A thin MCL leads to joint looseness and a specific pattern of elbow arthritis, called valgus extension overload.

All successful throwing athletes have changes in their elbow over the years. They all develop some thinning of the MCL and some level of arthritis. So “injury” is not the correct term. On occasion, the thinned ligament has an acute complete tear, but more typically it is a gradual thinning and arthritis in the elbow make a pitcher less effective.

Strengthening of the forearm muscles that stabilize the elbow can help manage symptoms and help throwers be effective again. If there is substantial laxity, the MCL can be reconstructed by taking a tendon from another part of the body and creating a new ligament. But this means a year off from throwing and does not always get throwers back to the same performance level.

https://sites.utexas.edu/sports-blog/pitchers-elbow/ ‎

This article was made by Hebah Mughal and David Ring

When reading “Ulnar Collateral Ligament Injuries of the Elbow in the Throwing Athlete” in an orthopedic journal recently, I was struck by how I interpreted best evidence distinctly from the authors.

It’s useful to see each of the original key points next to a suggested rewrite:

Original: “The anterior cord of the ulnar collateral ligament is the portion most commonly injured and is what is reconstructed.”

Rewrite: After years of frequent throwing the anterior band of the medial collateral ligament (MCL) of the elbow can become attenuated and lax. The word “injury” does not apply to most MCL insufficiency.

Original: “The ulnar collateral ligament is under the most stress during the late cocking and early acceleration phases of throwing.”

Rewrite: A notable percentage, if not a majority, of major league pitchers have some MCL insufficiency and valgus extension overload type of elbow arthritis. Instability severe enough to offer surgery is diagnosed on stress radiographs with the patient relaxed.

Original: “Magnetic resonance imaging is necessary to properly diagnose ulnar collateral ligament insufficiency.”

Rewrite: “An acute increase in symptoms can be due to an acute rupture or an episode of increased symptoms from long-standing insufficiency. It’s difficult to distinguish these two possibilities.”

Original: “Reconstruction is the primary treatment method for athletes. The modified Jobe and Docking techniques are the most commonly used operative techniques.”

Rewrite: The role of surgery for lesser degrees of ligament insufficiency is debatable. The desire for reconstruction in relatively young patients with limited instability may be related to psychosocial factors and seems increasingly common. There is a myth that reconstruction of the MCL can help people throw faster, and people often hope that it can get them to a higher level of competition.

Original: “For true acute ruptures of the ligament with ecchymosis and flexor pronator muscle injury, the role of nonoperative treatment, repair, and reconstruction with tendon graft are uncertain. The MCL heals predictably after elbow dislocation and would be expected to heal after isolated rupture as well.”

Rewrite: People with chronic MCL insufficiency have few symptoms in daily life. Athletes that decide to stop pitching may not benefit from ligament repair.

Original: “Athletes are able to return to competition, on average, between 12 and 20 months after the procedure with typically excellent outcomes.”

Rewrite: A notable percentage of athletes do not return to their prior level of competition after MCL reconstruction. Throwers that are considering MCL reconstruction should be aware of this, because it runs contrary to the ambitions of many younger athletes seeking MCL reconstruction in the hopes of not just continuing in their current level of competition, but ascending to a higher level of competition—something that seems very unlikely.