Should We Really Try To Eliminate All UCL Stress?
Last week the mailman delivered the monthly edition of my favorite medical journal, The American Journal of Sports Medicine! Like a kid on Christmas Morning, I immediately dug in searching for any pearl of wisdom that might help my students. I came across a study reporting the results of stress ultrasound imaging of the UCLs in young pitchers. 1
You can read the entire article by CLICKING HERE, but I will summarize…
Researchers performed ultrasounds while stressing the UCLs of 102 youth and adolescent pitchers. According to the data, “the UCL was significantly thicker in pitchers who threw more than 67 pitches per appearance (4.69 vs 4.14 mm), who pitched more than 5 innings per appearance (4.76 vs 4.11 mm), and who had more than 5.5 years of pitching experience (4.71 vs 4.07 mm; P \ .001).”1 The authors postulated that early UCL thickening might be a precursor to more serious arthritic changes such as spurring or calcification. They also referenced two previous studies suggesting that thickening of the UCL could be a predictor of future injury. 2,3
According to the physiologic principle known as Davis’s law, all connective tissue (including ligaments) organizes its cellular structure to resist the stress under which it is placed. So a UCL under stress would naturally begin to thicken, making it more robust and able to resist the extreme valgus stress of high level throwing. When that stress is applied too rapidly – faster than the ligament can adapt – tissue failure may occur. And when connective tissue is subjected to intense stress over a long period of time, the body ultimately lays down the precursors to the hardest structure it can muster – bone. This process first manifests itself in the form of calcium deposits in the ligament, tendon, or muscle under duress, or in spurring off the end of a bone.
The tone of the article suggests that early ligament thickening is a bad thing that could increase risk of failure later. But I was a bit perplexed by this supposition. I fired off an email to my friend, Dr. Ed Fehringer, an Orthopedic Surgeon from Omaha, Nebraska who specializes in shoulder and elbow surgery.
Here’s the email I sent:
Need your guidance on something.
In this week’s American Journal of Sports Medicine, they published an article in which researchers conducted Stress Ultrasound Studies (SUS) on bilateral UCLs of adolescent throwers. They found that subjects with more than 5 years experience pitching and those that had thrown more than 67 pitches per game had statistically significant thickening of their dominant UCL and hypoechoic tendencies. They referenced 2 previous stress ultrasound studies that suggested that ligament thickening “may be a predictor of future UCL injury”, but the referenced studies only postulated the theory. They did not actually show that thickening was a precursor to pathology. My question is this:
According to Davis’s Law, connective tissue remodels itself to resist the demands of stress applied. In my view, ligament thickening without calcification is probably a natural adaptation to higher throwing volume and should actually decrease the risk of tissue failure as long as the thickened ligament remains organized. The current paradigm in orthopedics appears to be to label all throwing injuries as “overuse”, and thus the treatment approach is to reduce stress.
Without stress there is no adaptation, so reducing it might actually be more risky. The key, as I see it, is to manage the stress. If we don’t push enough, we don’t get adaptation. If we push too fast, we get tissue failure. If we push too often or for too long, we get calcification.
Am I missing something?
Dr. Fehringer responded promptly:
“Hi Randy. Thanks for your note. IMO, you are spot on. I would expect they’d find thickened ligaments. They should….just as the dominant arms of tennis players are larger….and on and on. Just because two things are associated does not mean there is a cause/effect relationship.
The reflexive response to the increase in the injury rate among young pitchers seems to be to take a reductionist approach. Minimize exposure, simply movements, and eliminate all stress. But according to Davis’s Law, eliminating stress completely won’t solve the problem. On the contrary. Eliminating or reducing stress significantly might make the situation worse. Managing stress and adding it slowly over time… that is the Holy Grail.
So how do you know how much stress is too much? Well, that depends on the player… and that requires an assessment. Each guy is different. You have to know exactly where the athlete is on the spectrum of development, workload, and stress at all times. Only then can you prescribe an appropriate training plan customized for that player.
We’d love to conduct an assessment on you and help you come up with just the right training plan… But you gotta get here!
If you aren’t sure if you’re applying too much or too little stress… if you’re progressing too slowly, or too quickly, give me a call at 866-STRIKE3 (1-866-787-4533) and let’s get you signed up for an Elite Performers Boot Camp. We’ll conduct a full head-to- toe physical assessment and a high-speed video analysis of your throwing pattern. We’ll identify all the physical and biomechanical constraints that might be contributing to arm pain, putting you at risk for injury, negatively impacting your command and your secondary stuff, and robbing you of velocity optimization.
Our final 2 camps of the season are scheduled for Jan 21/22 and Feb 11/12. This will be your last chance to get engaged and locked in before the spring season. Our next camp won’t be until late May or early June.
Learn more by CLICKING HERE
Otherwise, call us at 1-866-STRIKE3 (866-787-4533) and we’ll get you set up.
We’ll see you at The Ranch!
Randy Sullivan, MPT
CEO, Florida Baseball Ranch
1. Atand A Jr, Averill LW, Wallace M, Niilker TA, Nazarian LN, Ciccoti MG. Factors Related to Increased Ulnar Collateral Ligament Thickness on Stress Sonography of the Elbow in Asymptomatic Youth and Adolescent Baseball Pitchers. Am J Sports Med. 2016;44 (12):3179-3187.
2.Atanda A Jr, Buckley PS, Hammoud S, Cohen SB, Nazarian LN, Ciccotti MG. Early anatomic changes of the ulnar collateral ligament identified by stress ultrasound of the elbow in young professional baseball pitchers. Am J Sports Med. 2015;43(12):2943-2949.
3.Ciccotti MG, Atanda A Jr, Nazarian LN, et al. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med. 2014;42:544-551.