Abstract
Background:
There is growing concern among sports medicine professionals regarding the increasing prevalence of ulnar collateral ligament (UCL) surgery in baseball players. At this time, it is unclear whether collegiate head baseball coaches possess adequate knowledge of UCL injuries.
Purpose/Hypothesis:
The purpose of this study was to assess the knowledge and perceptions of UCL injury among National Collegiate Athletic Association (NCAA) head baseball coaches. It was hypothesized that NCAA head baseball coaches would demonstrate misconceptions and knowledge disparities regarding UCL injury.
Study Design:
Cross-sectional study.
Methods:
An online 35-question survey was designed to assess NCAA head baseball coaches’ knowledge of UCL injury. The survey included questions related to participant characteristics, UCL injury, biometric performance and pitching variables, throwing fatigue, surgical variables/performance outcomes, and collegiate athlete recruitment. A total of 788 NCAA head baseball coaches were asked to participate. Responses were analyzed and reported using descriptive statistics where appropriate. Statistical comparisons and contrasts were made using chi-square and Fisher exact tests.
Results:
A total of 103 NCAA head baseball coaches participated in the survey, representing a 13.1% response rate. Only 31% of respondents could correctly identify all UCL injury symptoms, and 93% recommended <8 weeks off from overhead throwing during the off-season. Previous elbow injury observation was associated with UCL symptom identification (χ2 = 10.614; P = .005). Regular access to an athletic trainer (P = .015) and regular access to a strength and conditioning coach (P = .004) were both associated with NCAA division status, with Division I programs having the most access. Neither sports medicine physician (P = .656) nor athletic trainer (P = .611) access was associated with the geographic location of the baseball program; however, strength and conditioning coach access was associated with geographic location (χ2 = 6.696; P = .010).
Conclusion:
This study demonstrates that limited UCL injury knowledge and various misconceptions exist among NCAA baseball head coaches. The majority of responding coaches recommended an amount of time off from overhead throwing during the off-season that may be inadequate and were unable to identify all symptoms associated with UCL injury, representing the most concerning findings of the present study.
Overhead sports, especially the throwing of a baseball, produces significant upper extremity joint force within the elbow, which can lead to injury. The medial ulnar collateral ligament (UCL), which provides elbow valgus stability, is the ligament most likely to sustain injury from overhead throwing. Frank Jobe, an orthopaedic surgeon and co-founder of the Kerlan-Jobe Orthopaedic Clinic, performed the first UCL reconstruction (UCLR) in 1974. 16 Since the inception of this novel surgical procedure, concern regarding increased UCLR prevalence in baseball players at all levels of competition has grown in the sports medicine community. 1,7,13,33 In fact, several news sources have deemed this rise in UCL surgery an “epidemic.” 21,31 As demonstrated by Erickson et al, 13 UCL injuries occur most commonly in baseball players aged 15 to 19 years and 19 to 24 years. Interestingly, collegiate baseball players fall within these age groups. 26,27
Although UCLR has been shown to preserve the throwing career of injured collegiate baseball players, 4,9,10,22,32,34 surgical management inevitably interrupts the athlete’s overhead throwing career. After sustaining a UCL injury that results in UCLR, collegiate baseball players miss substantial time before returning to play (16.98 ± 6.16 months). 32 Specifically at the collegiate level, this window of time away from competitive play may influence an athlete’s draft stock. Moreover, performance outcomes are known to be variable after UCLR. The majority of athletes have been observed to return to preinjury performance levels, while other athletes demonstrate a decline in throwing performance or even do not return to the same level of competitive play. 11,15,19 Previous literature suggests that UCL injury risk may be reducible. 5,6,14,25,29,33 Thus, the avoidance of UCL injury in collegiate baseball players through mindful inclusion of prevention tactics is important.
Successful injury prevention in sports requires a multidisciplinary approach. The collegiate coach, a central component in the development and maintenance of a healthy sports environment, is a pivotal member of this multidisciplinary team. However, to positively contribute to injury prevention efforts, adequate knowledge of sport-related injuries and prevention strategies is necessary. Beyond injury prevention, a lack of knowledge among coaches regarding sport-related injuries may even inadvertently lead to injury predisposition. This sentiment has been observed in previous baseball literature with regard to UCL injury. 33 Thus, sufficient sport-specific injury knowledge held by coaches is important for the promotion of a culture of injury prevention within athletics.
Collegiate baseball coaches’ knowledge and perceptions of UCL injury have yet to be investigated. To the best of our knowledge, the only similar studies included professional baseball players, media, and public. 1,8,33 These survey-based investigations demonstrated misconceptions and knowledge disparities regarding UCLR in these populations. 1,8,33
Therefore, the main purpose of this study was to assess the knowledge and perceptions of National Collegiate Athletic Association (NCAA) head baseball coaches on the topic of UCL injury. A secondary purpose was to examine the influence of NCAA division status and geographic location, as well as program access to sports medicine personnel. Similar to previous literature examining other populations, we hypothesized that NCAA head baseball coaches would demonstrate misconceptions and knowledge disparities regarding UCL injury.
Methods
Participants and Data Collection
This study was approved by the research compliance and administration system at Baylor Scott & White Health System. A cross-sectional study was conducted to explore the knowledge and perceptions of UCL injury among NCAA head baseball coaches. An online survey (Qualtrics) was developed, and the head coaches of NCAA Division I, II, and III baseball teams were contacted via email at the address retrieved from each baseball program's website. A personalized email was sent to 788 head coaches requesting their participation, which included a hyperlink to access the Qualtrics survey. Two reminder emails were sent to all collegiate head coaches, resulting in a total of 6 weeks of data collection. The reminder email requested coaches to refrain from participation if they had already completed the survey. Data collection occurred between November 1, 2021, and December 6, 2021. Each collegiate head coach was required to provide informed consent at the beginning of the survey and agree to complete the survey without influence or assistance from outside sources (ie, search engines, coauthors, or peers).
Survey Details
The survey used in the current study is available separately as Supplemental Material. It was created based on an existing survey instrument, 33 with additive content drawn from current UCL injury literature. The survey development team included fellowship-trained sports medicine surgeons who provide care to NCAA Division I athletes (D.E.H. and B.D.G.). Included were 35 questions, with several different response styles including multiple choice, yes/no, and selection from a list of options. The majority of multiple-choice questions were presented as statements to which the degree of agreement was assessed using a 5-point Likert scale from strongly agree to strongly disagree. Questions were divided into 6 categories, as shown in Table 1. In this study, “all” UCL injury symptoms refers to the following: elbow stiffness, elbow soreness, issues with getting the throwing arm loose, numbness/tingling in the hand, difficulty with throwing motion, pain with extending the elbow, pain with flexing the elbow, and shoulder pain.
Categories of Questions From the Survey a
a UCL, ulnar collateral ligament.
Geographical Location of the Baseball Programs
Northern and southern schools were classified based on mean temperature by state. Zaremski et al 35 defined southern states as those with a mean temperature greater than 12.8°C (55°F) (the only exception was New Mexico at 11.8°C [53.2°F], which was considered a southern state) (Figure 1). Southern states included the following: Alabama, Arizona, Arkansas, California, Delaware, Florida, Georgia, Hawaii, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, and Virginia. All remaining states were classified as northern. In previous UCL literature, Erickson et al 12 also used temperature to delineate northern versus southern. The present study used the geographic state classification previously described by Zaremski et al.
Definition of northern and southern geographic regions of the United States. 35
Statistical Analysis
Responses were analyzed and reported using descriptive statistics where appropriate. Statistical comparisons and contrasts were made using chi-square and Fisher exact tests. All data were analyzed using the IBM Statistical Package for the Social Sciences Version 28 (IBM Corp), and figures were compiled using GraphPad Prism. A significance level of P < .05 was used.
Results
A total of 103 NCAA head baseball coaches participated in the survey, representing a 13.1% response rate. Of participating coaches, 96 completed all questions, representing a 93.2% survey completion rate. Overall, there were 19 (18%) Division I coaches, 28 (27%) Division II coaches, and 56 (54%) Division III coaches represented. Of 94 total conferences across all NCAA baseball divisions, 56 (60%) were represented in the study. Eleven of 31 (35%) Division I baseball conferences, 14 of 22 (64%) Division II conferences, and 31 of 41 (76%) Division III conferences participated in the survey. Geographically, 28 of 50 (56%) states were represented in the study. A total of 69 (70%) coaches were from northern states, and 29 (30%) were from southern states. More details regarding respondent demographic questions can be found in Table 2.
Demographics of the Participating NCAA Head Baseball Coaches (N = 103) a
a NCAA, National Collegiate Athletic Association.
Of responding coaches, only 53% believed UCL injuries can be prevented. Surprisingly, 52.5% of coaches stated that they did not believe UCL injuries can be caused by throwing a large number of pitches in a single outing. When asked about UCL injury symptoms, only 32 (31%) participants could correctly identify all 8 (Figure 2). A total of 99 (96%) coaches could identify at least 1 symptom, and 65 (63%) could identify at least 5 symptoms. Witnessing an athlete sustain an elbow injury in the past was associated with UCL symptom identification (χ2 = 10.614; P = .005). Of coaches who had witnessed an elbow injury in the past, 39% were able to identify all UCL symptoms, compared with 5% of coaches who had never witnessed an elbow injury. Age (χ2 = 0.607; P = .962), geographic location (χ2 = 1.513; P = .469), NCAA division status (χ2 = 4.091; P = .394), and years of collegiate coaching experience (P = .980) were not associated with UCL symptom identification. More details regarding responses to UCL injury-related questions can be found in Table 3.
Responding National Collegiate Athletic Association coaches’ ability to identify ulnar collateral ligament (UCL) symptoms.
Coaches’ Responses to Questions Related to UCL Injuries a
a NCAA, National Collegiate Athletic Association; UCL, ulnar collateral ligament.
Of the responding coaches, 45% neither agreed nor disagreed as to whether a player’s body mass index plays a role in UCL injuries. When asked at what age baseball players are most likely to tear their UCL, 98% of responding coaches reported either 15 to 19 or 20 to 26 years of age. In addition, 69% of respondents believed that baseball athletes who pitch at a higher velocity are more likely to sustain a UCL injury. More details regarding responses to biometric performance variable questions can be found in Table 4.
Coaches’ Responses to Questions Related to Biometric Performance Variables a
a UCL, ulnar collateral ligament.
When asked how much time a player should refrain from throwing during the off-season, 93% of coaches recommended less than 8 weeks (Figure 3A). Age (P = .866), geographic location (P = .536), NCAA division status (P = .511), previous witnessing of a UCL injury (P = .152), and years of collegiate coaching experience (P = .877) were not associated with respondents’ beliefs about time off from throwing. When asked which pitch type puts a player at the most risk of sustaining a UCL tear, only 13% correctly reported a 2- or 4-seam fastball. Further, 2% of coaches reported curve ball (Figure 3B). In a follow-up question, when asked if throwing a higher percentage of fastballs increases the risk of UCL injury, 31% of respondents neither agreed nor disagreed, and 54% of respondents disagreed. The majority (55%) of responding coaches did not believe that a 6-man starting rotation will decrease the risk of UCL injuries (Figure 3C). More details regarding responses related to throwing fatigue and pitching variables can be found in Table 5.
National Collegiate Athletic Association head baseball coaches’ response percentages to the following: (A) how much time a player should refrain from throwing during the off-season, (B) which pitch type puts a player at the most risk of tearing his ulnar collateral ligament (UCL), and (C) if a 6-man starting rotation will decrease the risk of UCL injuries.
Coaches’ Responses to Questions Related to Throwing Fatigue and Pitching Variables a
a UCL, ulnar collateral ligament.
When asked if a pitcher’s velocity increases after UCLR, 62% of responding coaches neither agreed nor disagreed. Among the respondents, 43% believed that pitchers often or usually return to their preinjury performance levels after UCLR. When asked if previous UCLR would affect recruiting decisions, 11% of respondents stated that it is likely. More details regarding responses related to surgical variables/performance outcomes and college recruitment can be found in Table 6.
Coaches’ Responses to Questions Related to Surgical Variables/Performance Outcomes and College Recruitment
Of responding coaches, 94% had regular program access to a sports medicine physician, 48% had regular program access to a certified athletic trainer, and 81% had regular program access to a strength and conditioning coach (Table 7). Access to a sports medicine physician was not associated with NCAA division status (P = .839). All responding Division I programs and 93% of responding Division II and III programs had access to a sports medicine physician (Figure 4A). Interestingly, access to a certified athletic trainer (P = .015) and access to a strength and conditioning coach (P = .004) were both independently associated with NCAA division status. Compared with 80% of Division I coaches with regular access to a certified athletic trainer, Division II and Division III had 39% and 41% access, respectively (Figure 4B). All Division I programs had access to a strength and conditioning coach (Figure 4C). Division III was found to have the least (69.6%) strength and conditioning coach access. Access to a sports medicine physician (P = .656) or certified athletic trainer (P = .611) was not associated with geographic location. Interestingly, strength and conditioning coach access was associated with geographic location (χ2 = 6.696; P = .010). A greater number (97%) of responding coaches from southern states had program access to strength and conditioning coaches compared with coaches from northern states (74%).
Program Access to Sports Medicine–Related Personnel
Access to sports medicine–related personnel by National Collegiate Athletic Association (NCAA) division status: (A) access to sports medicine physician by NCAA division, (B) access to certified athletic trainer by NCAA division, and (C) access to strength and conditioning coach by NCAA division.
Discussion
A total of 103 NCAA head baseball coaches participated in the survey, representing a 13.1% response rate. Only 31% of respondents could correctly identify all UCL injury symptoms, and 93% recommended <8 weeks off from overhead throwing during the off-season. Previous elbow injury observation was associated with UCL symptom identification (χ2 = 10.614; P = .005). Only about half (53%) of surveyed NCAA baseball head coaches reported that they believe UCL injury risk can be reduced. Regular access to an athletic trainer (P = .015) and regular access to a strength and conditioning coach (P = .004) were both associated with NCAA division status, with Division I programs having the most access.
This is the first study to evaluate NCAA head baseball coaches’ knowledge and perceptions regarding UCL injury. Previous UCL questionnaire studies have assessed the knowledge of the media, professional baseball players, coaches, parents, and the general public regarding UCLR. 1,7,33 Baseball head collegiate coaches may be valuable in the recognition and prevention of injuries. 2,20 This study sought to add novel insight to the current UCL literature regarding the knowledge and perceptions of UCL injuries currently held by NCAA head coaches. This study demonstrates that inadequate UCL injury knowledge and misconceptions exist among NCAA baseball head coaches. These variables include identification of UCL injury symptoms, time off from overhead throwing during the off-season, number of players in the starting rotation, and pitch type.
The current literature supports the idea that UCL injury rate reduction is possible. 5,6,14,25,29,33 Nonetheless, only a slim majority (53%) of our surveyed head baseball coaches agreed with this sentiment. A belief among NCAA head baseball coaches that UCL injuries are unavoidable may lead to neglect of proper arm care and injury prevention programs, among other harmful sports practices. 2,20
Insufficient off-season rest and throwing fatigue are among the most common risk factors for UCL injury. 29 Surprisingly, 93% of participating coaches in our survey recommend a player take <8 weeks off from throwing a baseball during the off-season. In contrast, the USA Baseball Medical and Safety Advisory Committee recommends no overhead throwing of any kind for at least 4 weeks and that players refrain from pitching for 8 to 12 weeks (4 months is preferred) per year, to prevent upper extremity overuse injury. 24 Similar to the USA Baseball Medical and Safety Advisory Committee, James Andrews, a trusted sports medicine surgeon and UCLR pioneer, recommends that players refrain from overhead throwing for a minimum of 2 months during the off-season, but states that 3 to 4 months is preferred. 3 The American Sports Medicine Institute recommends that elite-level baseball players should not throw a baseball from the end of their season in October until January (ie, at least 2 consecutive months). 23 Only 7% of surveyed head baseball coaches recommended 8 to 12 weeks off from overhead throwing, which appears to be the preferred time frame. 3,23,24 The majority (53%) of NCAA head coaches in our survey recommended 4 to 6 weeks of time off from overhead throwing. Startlingly, 3% of coaches recommended no time off at all, and 9% endorsed 1 to 2 weeks. In summary, 93% of surveyed coaches in the present study recommended an amount of time off from throwing during the off-season that may be inadequate (ie, <8 weeks).
Although the majority (90%) of responding coaches in the present study agreed that seasonal fatigue is associated with UCL injuries, 55% of coaches stated that a 6-man starting rotation would not decrease the risk of UCL injuries among pitchers. The potential benefits of a 6-man starting rotation have been observed in Japanese professional baseball, as UCL injury rates are lower in this population compared with Major League Baseball (MLB). 28 Although there are several differences between American and Japanese baseball players, the 6-man pitching rotation is perhaps the most obvious. Because of this starting rotation, Japanese pitchers are allotted a minimum of 5 rest days between games compared with approximately 4 days when using a 5-man starting rotation. 28 Further research is needed to explore the association between starting rotation and UCL injury risk, as this may provide helpful insight regarding UCL injury prevention.
Only 31% of all participating NCAA head baseball coaches in the present study could identify all UCL injury symptoms. UCL symptom identification was not associated with age of respondent, NCAA division status, years of collegiate coaching experience, or geographic location. Interestingly, previous observation of an elbow injury was associated with UCL symptom identification (χ2 = 10.614; P = .005). Of responding coaches, 39% of coaches who had witnessed an elbow injury in the past were able to identify all UCL symptoms, compared with 5% of coaches who had never witnessed an elbow injury. This is an alarming finding, as coaches are valuable in the recognition and prevention of UCL injuries.
In terms of pitch type, 40% of responding coaches reported that pitch type does not influence injury risk. Only 15% of surveyed coaches reported that 2- or 4-seam fastball or curveball pitching places a player at increased risk of UCL injury. However, the current literature indicates that fastball and curveball pitching may increase a player’s risk of UCL injury. 17,18,30 Lyman et al 18 demonstrated that curveball pitching increased the risk of elbow injury and shoulder pain in young pitchers. In a cohort of MLB pitchers, Keller et al 17 observed an increased rate of UCL injury in pitchers who threw a higher percentage of fastballs (P = .035). Previous work indicates that increased ball velocity is associated with higher elbow varus torque in professional baseball pitchers (P = .03), thus increasing UCL injury risk. 30 The results of the present study suggest that further education regarding the association between pitch type and UCL injury risk in NCAA baseball coaches may be warranted.
Although the majority (55%) of surveyed coaches stated that previous UCLR was unlikely to influence their recruiting decision, 34% of coaches responded neither likely nor unlikely, and 11% answered that it was somewhat likely. This is an interesting finding, as the literature regarding the influence of previous UCLR on baseball performance outcomes remains unclear. Previous literature observing professional baseball player outcomes after UCLR is conflicting. Some evidence suggests that UCLR may lead to an overall decline in pitching performance, while other works demonstrate no change in performance outcomes. 11,15,19 Several studies have shown a decreased earned run average and walks plus hits per inning pitched after returning to play. 11,19 Jiang and Leland 15 assessed pitching velocity before and after UCLR in MLB players and found no significant differences in velocity. Although performance outcomes for MLB players who have undergone UCLR are well-documented in the literature, 11,15,19 there remains a paucity of knowledge regarding performance outcomes in collegiate baseball players. Future research should examine postoperative performance outcomes after UCLR among collegiate baseball players.
Almost all responding NCAA head coaches in the present study reported that their program has regular access to a sports medicine physician, regardless of division status. Interestingly, access to an athletic trainer (P = .015) and access to a strength and conditioning coach (P = .004) were both independently associated with NCAA division status. The majority (80%) of Division I coaches had regular access to an athletic trainer, compared with Division II (39%) and Division III (41%). All Division I programs had access to a strength and conditioning coach. Division III was found to have the least (69.6%) strength and conditioning coach access. A greater number (97%) of responding coaches from southern states had program access to strength and conditioning coaches compared with coaches from northern states (74%). The results from this study indicate that greater uniform access to sports medicine personnel is needed among NCAA baseball programs.
Limitations
The present study has several limitations. The questionnaire did not undergo a formal validation process; however, it was developed based on a preexisting instrument 1,8,33 and created with the influence of 2 fellowship-trained sports medicine surgeons. The low response rate of 13.1% is a possible source of selection bias in those that decided to participate. Thus, it is important to note that the responses to the survey may not reflect the collective knowledge and perceptions of all NCAA head baseball coaches. All NCAA divisions and geographic locations were not equally represented, which reduced the ability to identify divisional status and differences associated with geographic location. To minimize survey completion time, only 35 questions were included. Certain questions that could have elicited interesting findings were excluded, such as usage of arm care programs and various coaching techniques. Additionally, to increase coaching anonymity, state location was not assessed. Geographic location was thus determined by the location of conference headquarters.
Conclusion
This study demonstrates that limited UCL injury knowledge and various misconceptions exist among NCAA baseball head coaches. The majority of responding coaches recommended an amount of time off from overhead throwing during the off-season that may be inadequate and were unable to identify all symptoms associated with UCL injury, representing the most concerning findings of the present study. Future research should explore mechanisms to increase UCL injury knowledge among NCAA baseball head coaches.
Supplemental Material for this article is available at https://journals.sagepub.com/doi/full/10.1177/23259671221141442#supplementary-materials
Supplemental Material
Supplemental Material, sj-pdf-1-ojs-10.1177_23259671221141442 - Knowledge and Perceptions of Ulnar Collateral Ligament Injuries in Baseball Players: A Survey of NCAA Head Baseball Coaches
Supplemental Material, sj-pdf-1-ojs-10.1177_23259671221141442 for Knowledge and Perceptions of Ulnar Collateral Ligament Injuries in Baseball Players: A Survey of NCAA Head Baseball Coaches by Mason F. Beaudry, Anna G. Beaudry, Brett C. Benzinger, Bradley D. Gilliam and David E. Haynes in Orthopaedic Journal of Sports Medicine
Footnotes
Final revision submitted September 13, 2022; accepted September 16, 2022.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.D.G. has received education payments from Pylant Medical and hospitality payments from Arthrex. D.E.H. has received education payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was waived by Baylor Scott & White Health.
References
Supplementary Material
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