The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Tear: A Longitudinal Study of 203 Professional Baseball Players

Adeeb Jacob Hanna, Hannah R. Popper, John Hayden Sonnier, Brandon J. Erickson, Robert A. Jack, Steven B. Cohen

Research output: Contribution to journalArticlepeer-review


Background: Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR). Purpose: To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury. Results: The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P =.006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P =.030). Players of both groups had similar dominant UCL thickness (P =.161), ulnohumeral joint space at rest (P =.321), space under stress (P =.498), and laxity (P =.796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs –0.60 mm, respectively; P =.038) and a greater increase in relative median UCL thickness (1.35 vs –0.35 mm, respectively; P =.045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P =.004). No differences in ulnohumeral stress spacing or laxity were detected. Conclusion: SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players.

Original languageEnglish (US)
Pages (from-to)1060-1067
Number of pages8
JournalAmerican Journal of Sports Medicine
Issue number4
StatePublished - Mar 2024


  • Major League Baseball
  • injury
  • stress ultrasound
  • ulnar collateral ligament

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation
  • Orthopedics and Sports Medicine


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