Continuing to Throw With Torn Ucl

• Journal List
• Int J Sports Phys Ther
• v.11(4); 2016 Aug
• PMC4970851

Int J Sports Phys Ther. 2016 Aug; 11(4): 614–626.

CHRONIC UCL INJURY: A MULTIMODAL APPROACH TO CORRECTING ALTERED MECHANICS AND IMPROVING HEALING IN A COLLEGE ATHLETE— A CASE REPORT

Rachel Patrick

¹Southern Rehab and Sports Medicine, Lagrange, GA, USA

Josh McGinty

²Southern Rehab and Sports Medicine, Lagrange, GA, USA

Ann Lucado

³Mercer University, Atlanta, GA, USA

Beth Collier

⁴Mercer University, Atlanta, GA, USA

ABSTRACT

Background

Ulnar collateral ligament (UCL) tears and associated Tommy Johns surgical intervention from excessive and poor quality pitching has increased immensely—with more college and professional pitchers undergoing the surgery in 2014 alone than in the 1990s as a whole.¹ Faulty mechanics developed at young ages are often well-engrained by the late adolescent years and the minimal healing ability of the largely avascular UCL often leads to delayed safe return to sport.²

Purpose

The purpose of this case study was to describe an innovative, multimodal approach to conservative management of a chronic UCL injury in a college-aged baseball pitcher. This innovative approach utilizes both contractile and non-contractile dry needling to enhance soft tissue healing combined with standard conservative treatment to decrease pain and improve sport performance as measured by the Disabilities of Arm, Shoulder and Hand (DASH), Numeric Pain Report Scale (NPRS), and return to sport.

Study Design

Retrospective Case Report

Case Description

A collegiate athlete presented to an outpatient orthopedic physical therapy clinic for treatment of UCL sprain approximately six weeks post-injury and platelet-rich plasma injection. Diagnostic testing revealed chronic ligamentous microtrauma. Impairments at evaluation included proximal stabilizing strength deficits, myofascial trigger points throughout the dominant upper extremity, improper pitching form, and inability to pitch in game conditions due to severe pain. Interventions included addressing strength deficits throughout the body, dry needling, and sport-specific biomechanical training with pitching form analysis and correction.

Outcomes

Conventional DASH and Sport-Specific scale on the DASH and the numeric pain rating scale improved beyond both the minimally clinically important difference and minimal detectable change over the 12 week treatment^3,4 At 24-week follow up, conventional DASH scores decreased from 34.20% disability to 3.33% disability while sport-specific DASH scores decreased from 100% disability to 31.25% disability. Although initially unable to compete due to high pain levels, the subject is currently completing his pitching role full-time with 1/10 max pain.

Discussion

The approach used in this case study provides an innovative approach to conservative UCL partial tear treatment. Dry needling of both contractile and non-contractile tissue in combination with retraining of faulty mechanics may encourage chronically injured ligamentous tissue healing and encourage safe return to sport.

Keywords: Baseball, biomechanics, dry needling, pitching, ulnar collateral ligament

BACKGROUND

Although a wide range of literature is available on the surgical repair of a fully torn ulnar collateral ligament (UCL), very little research has been published regarding the prognosis for conservative treatment in chronic partial UCL tears caused by long-term microtrauma and upper extremity repetitive overuse. Non-operative options for the large majority of UCL partial and complete tears are typically adequate for the non-athletic population.² However, when considering conservative treatment of high-demand throwing athletes with chronic partial or complete tears, return to sport at similar intensity is unlikely.² Bruce and Andrews published research assessing the benefits of a standardized, conservative four-month protocol focusing on upper extremity strength and range of motion.² This protocol when implemented in isolation reveals only a 42% return to sport.²

Due to the frequency of UCL injury, particularly in young athletes, a variety of risk factors have been associated with the potential for UCL damage.² Pitch counts both per game and per season in young athletes have been significantly linked to future UCL injury.^2,5 Players who pitch more than 100 innings per year experience a 3.5 times greater likelihood of upper extremity injury.^6,7 Those individuals pitching more than eight months per year had a 500% increased likelihood for later surgery, indicating that shear number of pitches plays a larger role than pitch type.^2,5 A variety of pitching limit protocols are now available based on pitches per game, week, season, and year to address the epidemic that UCL injury has become.²

Dry needling of muscles is used to decrease myofascial trigger points their resultant pain; additionally it is an innovative approach to inducing microtrauma to the ligament, which is believed to encourage healing via re-stimulation of the inflammatory cycle.⁸ Studies performed by Lewit and Dunning have shown that trigger point dry needling of muscle tissue results in both immediate and long-term relief via the needle effect.^8,9 Lewit has defined this needle effect as the "immediate analgesia produced by needling the pain spot".⁹ Very little research exists regarding dry needling in combination with electrical stimulation as compared to dry needling alone, as the majority of research investigates the benefits of electroacupuncture.⁸ Dunning describes the utilization of electrical stimulation in conjunction with dry needling to muscle tissue has been shown to produce a local twitch response (LTR), which has been suggested and shown in small samples to reduce pain with decreased post-treatment soreness by inducing a spinal reflex resulting in a motor, efferent response of the alpha motor neuron pool.⁷ Needles are inserted at desired points along the muscle, and continuous electric pulses are generated between those needles using clipped on electrical stimulation.⁸

Although dry needling of ligaments is less typically utilized when compared to trigger point dry needling (DN), utilizing dry needling to re-initiate the inflammatory process of a chronically injured tissue has shown promise in small studies.⁸ Similar in thought to the microfracture procedure that is utilized in surgeries of poorly vascularized tissues such as articular cartilage, small sterile perforations are made into the ligament to provide a newly "injured" environment and encourage new tissue formation in tissues that do not typically heal spontaneously.⁸ Although success rates of microfracture of bone in young patients ranges from 75-80%, very few studies have assessed the use or success rates of dry needling in this form, particularly for ligaments.¹⁰ A similar technique known as percutaneous needle tenotomy has been investigated in cases of delayed healing due to scar tissue resulting from avulsion fractures.¹¹ This technique uses rapidly pistoning insertions to encourage neovascularization and the healing response, which Schoensee et al revealed full return to sport and full functional recovery.¹¹ However, their sample size was small and the attempts discussed in the study focused on lower extremity injury. The theory behind this intervention is based on the idea that restoration of healing after needle insertion is natural and allows the body to "reset" the initial healing process, ideally disrupting the cyclic inflammatory process of chronically injured tissues.⁸ Dry needling of both superficial and deep non-trigger point regions has been shown to increase activity of pain inhibition systems in addition to decreasing limbic system activity.⁸ Based on basic understanding of tissue healing strategies utilizing both intrinsic and extrinsic responses and success in similar interventions such as microfracture, the rapid pistoning technique used in the needling intervention also ensures that all or most of the sensitized nerve endings are addressed in hopes of breaking the chronic pain cycle.⁸

Platelet rich plasma (PRP) injections are typically utilized in muscle and tendon injuries to encourage growth factors to surround the injury and promote healing utilizing a blood product.¹² Literature review demonstrated that the majority of the research involving PRP focuses on tendon repair and healing with significantly less evidence existing concerning the benefits of PRP injections for ligament healing.¹² A case series has been published regarding PRP injection to partially torn UCLs in which the subjects had failed two months of conservative treatment. Players receiving the injection demonstrated an 88% return to sport at 12 weeks, with a 70-week follow up revealing varying degrees of continued UCL injury.¹² This case series, however, did not combine the PRP injection with form analysis and correction of faulty mechanics thus subjecting the subject to a potential return to sport in which the same forces that originally injured the UCL were reinitiated. Although this option may show some promise in allowing athletes to return to sport, multi-season re-injury rates were not studied.

Relatively little research exists regarding a combination of these approaches particularly in the high-level athlete with a goal of safe return to sport. Focus on the various tissues involved and their respective pain mechanisms allows both treatment of the local pain source as well as potential contributing factors, such as form retraining and neuromuscular re-education.¹³ Utilizing these well-established form techniques to address form dysfunction in combination with various novel soft tissue techniques, the goal was to maintain low pain levels and decrease likelihood of full UCL tear during the return to the complex, repetitive motions of pitching.

Pitching Mechanics

UCL injury in throwing athletes has been associated with decreased balance and lead leg strength.^13,14 As a result of the decreased efficiency of the lower extremity during an athletic movement, it is thought that compensation occurs via excessive force throughout the upper extremity joints during the pitching motion in order to achieve identical velocity.¹³ In quantitative terms, a 20% decrease in kinetic energy from the hip and trunk musculature requires an additional 34% increase in the rotational velocity of the shoulder complex to transfer identical force to the hand and thus the ball.² Based on this description by Bruce and Andrews, pitching as a whole should never be considered solely an upper extremity action. However, many individuals with UCL injuries are treated conservatively with a focus on scapular and shoulder stabilization exercises, rotator cuff and forearm strengthening, and restoration of full glenohumeral joint internal rotation motion without fully addressing the core and lower body.^6,7 The general goal of physical therapy (PT) should be to optimize the efficiency of the entire kinetic chain, which could reduce shear force at the elbow joint and minimize the amount of micro-trauma with repetitive loading.^13,14

Although the bony anatomy of the elbow allows for partial joint stabilization during functional motions, valgus restraint during 20-120 ° of elbow flexion primarily relies on surrounding soft tissue including the UCL.¹⁶ The UCL contains three bundles termed the anterior oblique ligament (AOL), the transverse ligament, and the posterior oblique ligament (POL). The AOL is the strongest of the three bundles and is the only bundle that provides significant stabilization and resistance of valgus forces while the elbow moves throughout the flexion range of 30-120 °. The AOL originates at the anterior/inferior aspect of the medial epicondyle extending to its insertion just distal to the ulnohumeral joint at the sublime tubercle of the ulna as seen in Figure 1. The AOL typically requires forces of 260 N or greater before failure occurs. However, medial shear forces during a typical throwing motion in a collegiate player frequently exceed 300 N.^13,15

UCL anatomy (©Alila Medical Media, used with permission)

The phases involved in baseball pitching have been extensively studied, analyzed, and critiqued in order to determine the form that minimizes general joint stress.^14,15,16 Pitching has been dissected into six different widely accepted phases: windup, early cocking/stride, late cocking/stride, acceleration, deceleration, and follow through.¹⁷ The early cocking/stride phases through the beginning of the deceleration phase require relatively high valgus forces with maximal valgus force occurring at the end of arm cocking as seen in Figure 2.¹⁷ This valgus force must be countered by ligament stability, but dynamic stability relies largely on the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS).^14,19 In addition, as previously mentioned hip and knee stability and strength play a major role in stabilization of the lead leg to encourage efficient and adequate transfer of energy throughout the kinetic chain.¹⁴ Power generation from the larger muscle groups of the lower extremity—particularly from the hip abductors and rectus femoris to allow adequate stability and energy transfer from the lead leg is crucial to prevent overcompensation of the upper extremity and to minimize torque placed through the elbow.^14,15,16 Even if an athlete continues to perform the throwing motion with adequate strength but without adequate endurance, these lower extremity and core muscles fatigue with high pitch counts and begin to increase reliance on both upper extremity strength and ligamentous stability for overall joint stabilization.^13,14,15,16

The Six Phases of Pitching17 (Copyright 2009 American Orthopaedic Society for Sports Medicine, used with permission)

The purpose of this case study was to describe an innovative, multimodal approach to conservative management of a chronic UCL injury in a college-aged baseball pitcher. This innovative approach utilizes both contractile and non-contractile dry needling to enhance soft tissue healing combined with standard conservative treatment to decrease pain and improve sport performance as measured by the Disabilities of the Arm, Shoulder, and Hand (DASH), the numerical pain rating scale (NPRS), and return to sport.

CASE DESCRIPTION

Examination

The subject was a 20-year-old male baseball pitcher of athletic build beginning his junior year at a Division I college with no significant past medical history. The subject reported a slow onset of pain in April of 2015, which fully limited his participation in the sport approximately two weeks after initial pain onset associated after a game performance. The subject consulted with his team trainer and orthopaedic surgeon who diagnosed him with Grade I and "borderline" Grade II UCL sprain, indicating minor tearing of the anterior bundle of the UCL with very mild increase in joint space and laxity and edema within the trochlea using magnetic resonance imaging (MRI). The subject presented approximately six weeks after ceasing pitching activity and receiving one PRP injection to the injured UCL. Despite six weeks of limiting throwing, he continued to report 7-10/10 pain on the numeric pain rating scale (NPRS) during the early phases of throwing (primarily late cocking, early acceleration) and 1/10 pain with mild difficulty performing other activities of daily living such as turning door handles or opening jars.

Initial gross manual muscle testing revealed only mild strength deficits of the shoulder and wrist as seen in Table 1.¹⁸ Scapulothoracic testing revealed inability to recruit the middle and lower trapezius without significant compensation from the upper trapezius bilaterally. This strength limitation resulted in minor scapular dyskinesia throughout active performance of upper extremity elevation and abduction as the protracted scapulae were unable to rotate effectively through full range when starting in this position. Middle and lower trapezius were recruited through tactile and verbal cuing, and when activated the scapulae were able to complete full rotation bilaterally during the examination. Subsequent testing of the lower extremity, not initially performed due to focus on achieving full upper extremity strength, can be seen in Table 2. Range of motion examination data is presented in Table 3. The subject was mildly tender to palpation (1/10 on the NPRS) over the medial elbow. Special testing revealed a positive valgus stress test for increased laxity (Grade 4 indicating "slight hypermobility" on the manual grading of accessory joint motion scale) on the right when compared to the left with no associated pain.

Table 1.

Upper Extremity Manual Muscle Testing

	Shoulder ER and IR	Middle and Lower Trapezius	Elbow Flexion and Extension	Wrist Pronation and Supination
Initial Evaluation	4/5	3+/5 with UT compensation	5/5	4/5
12-Week Follow Up	5/5	4+/5	5/5	5/5
24-Week Follow Up	5/5	5/5	5/5	5/5

Table 2.

Lower Extremity Manual Muscle Testing

	Glute Max/Med	Knee Extensors	Knee Flexors	Ankle
Initial Evaluation	NT	NT	NT	NT
12-Week Follow Up	3+/5*	4+/5	5/5	5/5
24-Week Follow Up	4+/5	5/5	5/5	5/5

Table 3.

Range of Motion and Flexibility

	GH IR (R)	GH ER (R)	Total GH Rotational Arc (R)	Total GH Rotational Arc (L)	90/90 Hamstring Flexibility
Initial Evaluation	Lacking 10 °	110 °	190 °	180 °	Lacking 25 ° bilaterally
12-Week Follow Up	Lacking 7 °	110 °	193 °	180 °	Lacking 20 ° bilaterally
24-Week Follow Up	Lacking 5 °	110 °	195 °	180 °	Lacking 20 ° bilaterally

Outcome Measures

The DASH outcome tool scores throughout treatment can be seen in Figure 3. The DASH is a 30-item self-report questionnaire utilized to determine arm pain and function in athletes and workers who require relatively high levels of ability and has been shown to be both valid and reliable.^3,4,20 Scoring ranges from 1 (no difficulty) to 5 (unable) and includes reporting on various activities of daily living.¹⁸ A score of 100% would thus indicate 100% disability. The DASH also contains an optional four-item high performance sport-specific module in which the subject is questioned regarding their individual ability to participate in sport.^3,4,20 Minimal detectable change and minimally clinically important difference for intercollegiate athletes utilizing the DASH have both been reported as 10 points.^3,4,20 Baseline assessment revealed 100% disability in sport with 34.2% disability on the DASH.

Functional Testing

Although not initially assessed, functional pitching observation using UberSense® (www.hudl.com) slow motion video revealed altered pitching mechanics, particularly throughout the early and weight-transfer phases. This functional observation was initiated after MRI results revealed healing of the UCL ten weeks after initial evaluation. Figures 3-​ 6 are images of the subject discussed in this case report captured through the UberSense® application. Major deviations found in the subject that differed from ideal form that may have contributed to the UCL trauma are summarized in Table 4.

Acceleration phase (a=early, b=mid)

Table 4.

Body Mechanics Analysis of the Subject During Pitching Motion

Phase	Ideal Mechanics	Altered Mechanics Specific to this Case	Result
Windup	Full weight shift to trailing leg to maximize energy buildup	Decreased weight shift to trailing leg	Decreased availability of potential energy for transfer
Early Cocking/Stride	Lead leg remains off ground	Early weight shift onto lead leg	Dissipation of energy prior to acceleration phase
Late Cocking/Stride	Peak pelvic and peak torso velocities occur simultaneously	Early weight shift onto anterior lower extremity with lack of upper extremity advancement	Lack of area for lower extremity power transfer
Acceleration	Trunk flexion throughout pitching motion, continued simultaneous pelvic and torso rotation	Decreased trunk flexion, Overcompensation of upper extremity	Complete separation of lower and upper kinetic chain, increased torque and demand to upper extremity complex

Early Cocking/Stride phase

Late Cocking/Stride phase

INTERVENTION AND OUTCOMES

Physical therapy frequency was three times per week for five to six weeks followed by twice weekly for five to six weeks to ensure full healing of the UCL and to allow ample time for neuromuscular re-education with body mechanics and safe return to high-level throwing. Rehabilitation was divided into three phases.

Phase I: Upper Extremity Strengthening Weeks 1-4

Pain free range of motion and shoulder/scapular stabilization exercises were performed during this stage to maintain and eventually increase strength along the upper extremity portion of the kinetic chain. After elbow pain at rest resolved, focus on the wrist flexors and pronators and supinators began. This portion of therapy, based around the "Thrower's Ten" exercise set found in Appendix 2 is considered the typical conservative approach for UCL injury and lasted approximately six weeks.^21,23 In typical UCL injury protocols, after full restoration of the strength of this musculature is complete the subject may begin functional exercise including a throwing program. Subsequently, the subject may return to sport after pain-free completion of the chosen return to throwing program or progression.^19,21,23 In the subject of this case, despite full strength achievement throughout the upper body after approximately four weeks of intervention and ten total weeks of throwing cessation, pain free completion of a throwing program was not achieved.

Phase II: Dry Needling Weeks 5-6

Based on the assumption that continued pain was still stemming from chronically unhealed and inflamed tissue, dry needling was attempted five weeks after initial evaluation to initiate an additional acute inflammatory response and secondarily inhibit nociception from local tissues.^8,9 The first needling session was initiated approximately five weeks after physical therapy began. Trigger point dry needling of the flexor carpi radialis, flexor digitorum superficialis, and flexor digitorum profundus was perfomed to increase myofascial mobility to allow more efficient performance of the musculature by decreasing myofascial trigger points from chronic overutilization. The needles were retained in the target tissues, and connected to electrical stimulation (2 Hz via ITO ES-130 Three Channel Electro Stimulation Unit from Superior Medical Equipment in Wilmington, NC) to elicit a localized twitch response and remained in place for eight minutes to encourage post-synaptic pain modulation as previously discussed.⁸ When needling the injured non-contractile, avascular tissue, a pistoning technique was utilized with needles (0.23x15mm) placed in the proximal and lateral UCL, with placement based on the location of sprain indicated in original MRI. This technique was performed in hopes of re-initiating the extracellular healing cycle to allow improved healing time of the chronically injured and partially torn UCL which is often unable to adequately heal itself without signs of remaining laxity and dysfunction.² The subject continued therapy two times per week, and underwent dry needling again one week later by the same protocol as described above. A follow-up MRI approximately three weeks after the second dry needling treatment revealed significantly decreased tears and laxity with no associated edema. Dry needling was discontinued after this point, as no palpable trigger points were present within the forearm musculature and the initial goal of dry needling for ligament healing had been achieved. As full ligament healing at this point had been accomplished, form analysis was performed at the end of week six to assess pitching mechanics.

Phase III: Lower Extremity Strengthening and Form Analysis: Weeks 7-12

Approximately seven weeks after initial evaluation, the treatment focus shifted to target throwing mechanics and strengthening specific to the muscles of the kinetic chain utilized in a normal throwing motion. This focus was largely placed on mechanics, stability, and general strength throughout the lead (left) leg to provide increased general stability throughout the phases in which the most elbow valgus force typically occurs.^13,14 The acceleration phase has been shown to require adequate concentric rectus femoris strength to allow for hip flexion in addition to knee extension to increase angular momentum of the trunk through a properly stabilized lead leg.¹³ Providing a secure lead leg allows maximal hip flexion prior to ball release to decrease reliance on the upper extremity to create the force and associated velocity transmitted to the ball. Exercises to challenge stability included BOSU (BOSU in Ashland, Ohio) lunges for proprioceptive training, double-leg squats with focus on decreasing anterior tibial translation, single-leg eccentric squats, stride drills focused on arm elevation at lead-leg strike, single-leg deadlifts with maintenance of core stability, and concentric and eccentric four-way resistance band hip strengthening to address any instability throughout the lower extremity and core in situations where the lead leg may not land in optimal positioning. Stride drills specifically focused on the early cocking phase in which the subject would repeatedly perform the wind-up to early cocking portion of the pitch to ensure that the lead foot was pointed directly towards home plate with the dominant upper extremity elevated to 90 ° abduction, 90 ° ER, and 90 ° elbow flexion to optimize energy transfer in later phases and decrease forces required through the upper extremity.

Outcomes

After only one week of education regarding pitching mechanics via verbal and visual feedback, the subject reported significantly lower pain levels as seen in Table 5. These pain levels surpassed both the minimal detectable change (3 points) and minimally clinically important difference for chronic musculoskeletal pain (1 point) on the NPRS.⁴ Education regarding form involved part-practice utilizing partial task completion, avoiding full speed pitching at this time in order to continue to promote proper mechanics and neuromuscular re-education prior to initiation of return to sport intensity levels. Re-education at half speed was required to overcome maladaptive motor patterns as the subject was repeatedly unable to perform proper pitching form with education, instruction, and self-observation alone.

Table 5.

Subjective Pain Levels

	Throwing Speed (mph)	Pain Level (NPRS)
Initial Evaluation	88-90 (Full Speed)	10/10
After Dry Needling and Full UE Training	66-68 (75% Full Speed)	6/10
After 1 Week of Body Mechanics Retraining Implementation/12-Week Follow Up	66-68 (75% Full Speed)	3/10
24-Week Follow Up	88-90 (Full Speed)	3/10

Range of motion examination and strength examinations after this phase can be seen in the 12 and 24-week follow ups in Tables 1-​ 3. The subject returned to sport at the start of the following season serving as the closing pitcher and has repeatedly pitched what is considered a full game for his position at six month after injury with no pain at full speed and significantly decreased DASH scores as seen in Table 6, surpassing both the minimal clinically important difference and minimal detectable change.^3,4

Table 6.

Patient Reported Outcome Scores

	Conventional DASH	DASH Sport Subscale
Initial Evaluation	34.20% Disability	100% Disability
12-Week Follow Up	16.67% Disability	87.50% Disability
24-Week Follow Up	3.33% Disability	31.25% Disability

DISCUSSION

UCL injury is prevalent in young baseball athletes and surgery has become a common solution to this problem related to the long-term effects of microtrauma occurring due to altered throwing mechanics and muscle fatigue as a result of excessive repetitions.²² Although many patients are able to return to sport after surgery, relying on the surgical fixation of the UCL may not fully address the underlying problem, and many individuals continue to utilize the mechanics that created the injury—increasing shear force through the medial elbow and eventually resulting in an exacerbation of symptoms.²² With advancements in the understanding of this injury, it is believed by the authors of this case report that implementation of pitching biomechanical retraining and kinetic chain optimization early in the rehabilitation process in combination with these innovative non-contractile dry needling techniques can encourage healing in largely avascular tissues as confirmed by diagnostic testing. Due to the timing of the injury, the subject discussed in this report missed approximately half of his sophomore season prior to starting physical therapy—but returned without limitation or pain in his junior year.

Symptoms were initially treated locally with the belief that nociception was being generated from the injured UCL tissue. This pain, by definition, should cease upon tissue healing. In this case report ligament healing confirmed by MRI post-dry needling interventions correlated with reduced pain complaints, although all pain was not fully abolished. Further analysis into other pain mechanisms was required to address other potential contributing factors and encourage safe return to sport. Particularly in a functional movement where such complex multi-joint coordination is required, even minor alterations in form as a result of pain can encourage improper motor strategies. Understanding the role various pain mechanisms may play is key to full resolution of symptoms, and combining the dry-needling technique to abolish nociceptive pain with biomechanics retraining to diminish central sensitization and pain associated with altered motor patterns was shown to be successful in the management of this subject.

Although the subject did present with significant strength deficits in the upper extremity, the subject did not show any improvement in pain levels with activity after completing the traditional four to six weeks of upper extremity strengthening, stabilization, and stretching. Dry needling of the UCL for re-stimulation of the healing process appeared to encourage healing of a typically very slow-healing connective tissue, resulting in only minimal chronic abnormalities upon follow-up MRI. Implementation of the emergic technique of dry needling of non-contractile tissue allowed further assessment of biomechanical analysis due to the potentially associated healing phase progression. The residual pain despite a "healed" ligament as evidenced by MRI led the physical therapists to believe that the UCL was not the only source of symptoms for this subject, and that he may in fact be experiencing referred pain from other structures, such as trigger points in the pectoral muscles. Addressing the initially faulty pitching mechanics that resulted in overload of the shoulder complex may have aided in offloading the work of the shoulder internal rotators during a pitching motion, and thus may have decreased the pain that may have been associated with these potential referral patterns.

Initiation of body mechanics education using visual feedback, verbal cuing, and part practice once UCL healing had been documented provided near-immediate reductions in pain during throwing. Progression of the performance of biomechanical throwing training to near full speed during whole task performance allowed the assessment of activity and determination of significantly decreased pain levels.

When individuals undergo surgical repair whether due to partial or full UCL tear, average return to prior level of competition has been reported as 11.6 months.²² Even after return to sport, researchers suggest that only 67% return to similar levels of competition postoperatively with 57% returning to the disabled list due to later injuries of the throwing arm, implying lack of attention to actual contributing factors and symptom sources.²² Ideally, if techniques such as non-contractile dry needling can be implemented to break up the chronic pain cycle post-injury, these full-body interventions can be utilized earlier in the therapy plan to significantly decrease the amount of sport cessation required for adequate healing and surgical intervention could be prevented. In future studies, early combination of upper extremity stabilization training combined with lower extremity and core stabilization exercises to optimize the kinetic chain in addition to dry-needling of both contractile and non-contractile tissues may greatly decrease pain levels, healing time, and time required for safe return to sport. Further, education of proper throwing mechanics may prevent future damage to the UCL and prevent the need for surgical intervention, although further studies are needed to support this theory.

Limitations

This case report does have limitations in generalizability, as only one subject was assessed. No controls were utilized to assess healing times or return to sport measures with those who did not receive the aforementioned interventions. The outcome measures utilized in this report are standard to physical therapy, but no reliability or validity testing was performed on the individual completing those measures.

No diagnostic testing was performed just prior to dry needling, and thus it is unclear whether or not the aforementioned healing and mildly decreased subjective pain report after dry needling occurred specifically due to the re-initiation of the inflammatory cycle or if the UCL damage had healed secondary to time or an additional three weeks of activity modification. However, due to the prolonged healing process of the UCL and delay of the needling technique until 14 weeks post-initial-injury, it is believed that the re-initiation of the healing cycle through the dry needling technique may have significantly impacted the healing of the tissue. Further research is necessary to determine long-term benefits of non-contractile and avascular dry-needling techniques, and follow-up should include completion of the sport season as long-term follow up was not performed in this report. More quantitative strength analysis may have provided more objective results, and focus on myofascial restrictions and impairments of the glenohumeral internal rotator muscles would have provided a more complete image of involved contributing factors.

CONCLUSION

The case presented is that of a college-aged male diagnosed with partial UCL tear. Poor response to initial treatment in this case resulted in reassessment of plan of care and source of symptoms, followed by alteration of interventions. Focus on the altered pitching mechanics that may have been a contributing factor to the UCL damage was incorporated. The subject reported a significantly decreased score on both the NPRS and DASH and was able to fully return to sport the following season without pain.

Although the technique and benefits of dry needling particularly in non-contractile tissues continues to be a topic that is not fully understood, one theory suggests that re-initiation of the acute inflammatory process via intrinsic and extrinsic healing factors may impact healing time.^8,9,10 This case report has demonstrated how a better understanding of healing and pain mechanisms may improve patient care by addressing both the adequate healing of the acutely injured tissue in addition to addressing the contributing factors to injury as a result of the complex pitching motion. Further research and larger sample sizes are necessary to better determine the impact that dry needling may have on soft tissue healing.

Appendix 1.

Throwing Program Adapted from Andrews Sports Medicine ²¹

30' Phase	45' Phase
Step 1	Step 3
Warm-Up Throwing   30' 25 Throws   Rest 15 min   Warm-Up Throwing   30' 25 Throws	Warm-Up Throwing   45' 25 Throws   Rest 15 min   Warm-Up Throwing   45' 25 Throws
Step 2	Step 4
Warm-Up Throwing   30' 25 Throws   Rest 10 min   Warm-Up Throwing   30' 25 Throws   Rest 10 min   Warm-Up Throwing   30' 25 Throws	Warm-Up Throwing   45' 25 Throws     Rest 10 min   Warm-Up Throwing   45' 25 Throws   Rest 10 min   Warm-Up Throwing   45' 25 Throws
60' Phase	90' Phase
Step 5	Step 7
Warm-Up Throwing   60' 25 Throws   Rest 15 min   Warm-Up Throwing   60' 25 Throws	Warm-Up Throwing   90' 25 Throws   Rest 15 min   Warm-Up Throwing   90' 25 Throws
Step 6	Step 7
Warm-Up Throwing   60' 25 Throws   Rest 10 min   Warm-Up Throwing   60' 25 Throws   Rest 10 min   Warm-Up Throwing   60' 25 Throws	Warm-Up Throwing   90' 20 Throws   Rest 10 min   Warm-Up Throwing   45' 20 Throws   Rest 10 min   Warm-Up Throwing   45' 15 Throws

Appendix 2.

Thrower's Ten UE Strengthening Program ^21,23

Exercise Name	Performance
1. D2 Extension	Involved hand will grip tubing handle overhead and out to the side. Pull tubing down and across your body to the opposite side of leg. During the motion, lead with your thumb.
2. D2 Flexion	Gripping tubing handle in hand of involved arm, begin with arm out from side 45 degrees and palm facing backward. After turning palm forward, proceed to flex elbow and bring arm up and over the uninvolved shoulder. Turn palm down and reverse to take arm back to starting position. This exercise should be done in a controlled manner.
3. ER at 0 ° Abduction	Stand with involved elbow fixed at side, elbow at 90 degrees and involved arm across front of body. Grip tubing handle while the other end of the tubing is fixed to a stationary object. Pull out with arm, keeping elbow at side. Return tubing slowly and in a controlled manner.
4. IR at 0 ° Abduction	Standing with elbow at side, fixed at 90 degrees and should rotated out. Grip tubing handle while other end of tubing is fixed to a stationary object. Pull arm across body, keeping elbow at side. Return tubing slowly and controlled.
5. ER at 90 ° Abduction	Stand with shoulder abducted 90 degrees and elbow flexed 90 flexed. Grip tubing handle while the other end is fixed straight ahead, slightly lower than the shoulder. Keeping shoulder abducted, rotate the shoulder back, keeping elbow at 90 degrees. Return tubing and hand to start position.
6. IR at 90 ° Abduction	Stand with shoulder abducted to 90 degrees, externally rotated 90 degrees and elbow bent 90 degrees. Keeping shoulder abducted, rotate shoulder forward, keeping elbow bent at 90 degrees. Return tubing and hand to start position.
7. Shoulder Abduction to 90 °	Stand with arm at side, elbow straight, and palm against side. Raise arm to the side, palm down, until arm reaches 90 degrees (shoulder level). Hold 2 seconds and lower slowly.
8. Scaption, IR	Stand with elbow straight and thumb up. Raise arm to shoulder level at 30 degree angle in front of body. Do not go above shoulder height. Hold two seconds and lower slowly.
9. Prone Horizontal Abduction Neutral	Lie on table, face down, with involved arm hanging straight to the floor, palm facing down. Raise arm out to side, parallel to floor. Hold 2 seconds and lower slowly.
10. Prone Horizontal Abduction Full ER, 100 ° Abduction	Lie on table, face down, with involved arm hanging straight to the floor, thumb rotated up (hitchhiker position). Raise arm out to the side slightly in front of shoulder, parallel to the floor. Hold 2 seconds and lower slowly.
11. Press-Ups	Seated on a chair or table, place both hands firmly on the sides of the chair or table, palm down and fingers pointed outward. Hands should be placed equal with shoulders. Slowly push downward through the hands to elevate your body. Hold the elevated position for 2 seconds and lower slowly.
12. Prone Rowing	Lying on your stomach, with your involved arm hanging over the side of the table, dumbbell in hand and elbow straight. Slowly raise arm, bending elbow and bring dumbbell as high as possible. Hold at the top for 2 seconds, then slowly lower.

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Articles from International Journal of Sports Physical Therapy are provided here courtesy of North American Sports Medicine Institute

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970851/