{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,27]],"date-time":"2026-06-27T05:41:31Z","timestamp":1782538891332,"version":"3.54.5"},"reference-count":36,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,12,27]],"date-time":"2025-12-27T00:00:00Z","timestamp":1766793600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T00:00:00Z","timestamp":1769558400000},"content-version":"vor","delay-in-days":32,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Sports Sci Med Rehabil"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background and aims<\/jats:title>\n                    <jats:p>Return-to-play (RTP) readiness is a critical consideration for common baseball injuries, including after ulnar collateral ligament (UCL) injuries. UCL injuries, often resulting from repetitive throwing stress, can significantly impact an athlete\u2019s career, requiring interventions ranging from nonoperative rehabilitation to surgical reconstruction. While RTP criteria for these injuries exist, they remain inconsistent across studies and clinical practice. Commonly reported RTP criteria include achieving pain-free range of motion and completion of progressive throwing distances. This systematic review aims to analyze and compare different RTP criteria for UCL injuries in baseball players.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This systematic review follows the PROSPERO protocol (CRD42024607322) and adheres to the PRISMA guidelines. Three independent reviewers conducted a comprehensive search across PubMed, Scopus, and Embase to identify relevant studies. Search results were imported into Covidence for systematic screening and data management. Any disagreements or uncertainties in study selection were resolved by a fourth reviewer to ensure consistency and accuracy. After full-text screening and eligibility assessment, 18 articles were included for data extraction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Eighteen studies on UCL injuries (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20092887) were included. UCL injuries predominantly affected professional or collegiate pitchers in baseball and were linked to valgus stress during high-velocity throwing. Reported rehabilitation protocols varied, ranging from brief immobilization followed by progressive range-of-motion and throwing programs to structured three-month conservative interventions before considering surgery. RTP was assessed using objective performance metrics such as earned run average (ERA), walks and hits per inning pitched (WHIP), and advanced metrics like Wins Above Replacement (WAR). RTP rates ranged from 80% to 91%, with most players returning to their pre-injury level of competition. Some studies reported incomplete protocol adherence due to pain, lack of motivation, or pursuit of alternative treatments.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This review highlights inconsistencies and differences in RTP criteria for UCL injuries. Key influencing factors include treatment type, competition level, and psychological readiness. Although metrics such as ERA, WHIP, and imaging findings are frequently used, their application lacks uniformity. Standardized, multidisciplinary RTP protocols integrating physical, imaging, and psychological components are essential to guide safe and objective return-to-sport decisions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13102-025-01499-3","type":"journal-article","created":{"date-parts":[[2025,12,27]],"date-time":"2025-12-27T07:05:32Z","timestamp":1766819132000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Mechanisms of ulnar collateral ligament injury in baseball: criteria and rationale for return to play \u2014 a systematic review"],"prefix":"10.1186","volume":"18","author":[{"given":"Di","family":"Huang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William J.","family":"Lew","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brent","family":"Shimoda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eli M.","family":"Snyder","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kai Sheng","family":"Khor","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David X.","family":"Cifu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henry L.","family":"Lew","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,27]]},"reference":[{"key":"1499_CR1","doi-asserted-by":"publisher","first-page":"621","DOI":"10.1177\/03635465030310042601","volume":"31","author":"EL Cain","year":"2003","unstructured":"Cain EL, Dugas JR, Wolf RS, Andrews JR. Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med. 2003;31:621\u201335.","journal-title":"Am J Sports Med"},{"key":"1499_CR2","doi-asserted-by":"publisher","first-page":"233","DOI":"10.1177\/036354659502300218","volume":"23","author":"GS Fleisig","year":"1995","unstructured":"Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23:233\u20139.","journal-title":"Am J Sports Med"},{"key":"1499_CR3","doi-asserted-by":"publisher","first-page":"1764","DOI":"10.1177\/0363546515580792","volume":"43","author":"SA Conte","year":"2015","unstructured":"Conte SA, et al. Prevalence of ulnar collateral ligament surgery in professional baseball players. Am J Sports Med. 2015;43:1764\u20139.","journal-title":"Am J Sports Med"},{"key":"1499_CR4","doi-asserted-by":"publisher","first-page":"266","DOI":"10.1016\/j.jhsa.2021.11.026","volume":"47","author":"MD Gehrman","year":"2022","unstructured":"Gehrman MD, Grandizio LC. Elbow ulnar collateral ligament injuries in throwing athletes: diagnosis and management. J Hand Surg. 2022;47:266\u201373.","journal-title":"J Hand Surg"},{"key":"1499_CR5","unstructured":"Covidence systematic review software. Veritas Health Innovation, Melbourne, Australia. Available at: https:\/\/www.covidence.org."},{"key":"1499_CR6","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1016\/j.jclinepi.2018.01.012","volume":"111","author":"HJ Sch\u00fcnemann","year":"2019","unstructured":"Sch\u00fcnemann HJ, et al. GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used to rate the certainty of a body of evidence. J Clin Epidemiol. 2019;111:105\u201314.","journal-title":"J Clin Epidemiol"},{"key":"1499_CR7","doi-asserted-by":"publisher","first-page":"1159","DOI":"10.1016\/j.jse.2018.11.063","volume":"28","author":"PN Ramkumar","year":"2019","unstructured":"Ramkumar PN. Prognostic utility of an magnetic resonance imaging-based classification for operative versus nonoperative management of ulnar collateral ligament tears: one-year follow-up. J Shoulder Elbow Surg. 2019;28:1159\u201365.","journal-title":"J Shoulder Elbow Surg"},{"key":"1499_CR8","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1016\/j.csm.2020.02.007","volume":"39","author":"FH Savoie","year":"2020","unstructured":"Savoie FH, O\u2019Brien M, Sprains. Strains, and partial tears of the medial ulnar collateral ligament of the elbow. Clin Sports Med. 2020;39:565\u201374.","journal-title":"Clin Sports Med"},{"key":"1499_CR9","doi-asserted-by":"publisher","first-page":"S2","DOI":"10.1016\/j.jse.2022.02.006","volume":"31","author":"BM Heaps","year":"2022","unstructured":"Heaps BM, Haselman WT, ElAttrache NS. Return to play after ulnar collateral ligament reconstruction with concurrent posterior-compartment decompression. J Shoulder Elb Surg. 2022;31:S2\u20137.","journal-title":"J Shoulder Elb Surg"},{"key":"1499_CR10","doi-asserted-by":"publisher","first-page":"282","DOI":"10.1016\/j.jse.2017.09.004","volume":"27","author":"JP Begly","year":"2018","unstructured":"Begly JP, et al. Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players. J Shoulder Elbow Surg. 2018;27:282\u201390.","journal-title":"J Shoulder Elbow Surg"},{"key":"1499_CR11","doi-asserted-by":"publisher","DOI":"10.1177\/23259671221092728","volume":"10","author":"MJ Steffes","year":"2022","unstructured":"Steffes MJ, Heaps BM, ElAttrache NS, Haselman WT. Outcomes after medial ulnar collateral ligament graft repair in professional baseball pitchers with minimum 2-year follow-up. Orthop J Sports Med. 2022;10:23259671221092728.","journal-title":"Orthop J Sports Med"},{"key":"1499_CR12","doi-asserted-by":"publisher","first-page":"e245","DOI":"10.1016\/j.jse.2020.08.041","volume":"30","author":"CL Camp","year":"2021","unstructured":"Camp CL, et al. Players\u2019 perspectives on successfully returning to professional baseball after medial ulnar collateral ligament reconstruction. J Shoulder Elbow Surg. 2021;30:e245\u201350.","journal-title":"J Shoulder Elbow Surg"},{"key":"1499_CR13","doi-asserted-by":"publisher","first-page":"1990","DOI":"10.1177\/03635465221093995","volume":"50","author":"TB Griffith","year":"2022","unstructured":"Griffith TB, et al. Correlation of rehabilitation and throwing program milestones with outcomes after ulnar collateral ligament reconstruction: an analysis of 717 professional baseball pitchers. Am J Sports Med. 2022;50:1990\u20136.","journal-title":"Am J Sports Med"},{"key":"1499_CR14","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1053\/j.ajkd.2012.08.032","volume":"61","author":"M Jun","year":"2013","unstructured":"Jun M, et al. Outcomes of extended-hours hemodialysis performed predominantly at home. Am J Kidney Dis. 2013;61:247\u201353.","journal-title":"Am J Kidney Dis"},{"key":"1499_CR15","doi-asserted-by":"publisher","DOI":"10.1177\/2325967119839785","volume":"7","author":"PN Ramkumar","year":"2019","unstructured":"Ramkumar PN, et al. Clinical utility of an MRI-based classification system for operative versus nonoperative management of ulnar collateral ligament tears: a 2-year follow-up study. Orthop J Sports Med. 2019;7:2325967119839785.","journal-title":"Orthop J Sports Med"},{"key":"1499_CR16","doi-asserted-by":"publisher","DOI":"10.1016\/j.otsm.2020.150733","volume":"28","author":"MC Iloanya","year":"2020","unstructured":"Iloanya MC, Savoie FH, O\u2019Brien MJ. Nonoperative treatment of ulnar collateral ligament injuries. Oper Tech Sports Med. 2020;28:150733.","journal-title":"Oper Tech Sports Med"},{"key":"1499_CR17","doi-asserted-by":"publisher","DOI":"10.1016\/j.otsm.2020.150735","volume":"28","author":"RS O\u2019Connell","year":"2020","unstructured":"O\u2019Connell RS, O\u2019Brien M, Savoie FH. Primary repair of ulnar collateral ligament injuries of the elbow. Oper Tech Sports Med. 2020;28:150735.","journal-title":"Oper Tech Sports Med"},{"key":"1499_CR18","doi-asserted-by":"publisher","first-page":"3359","DOI":"10.1177\/0363546520951529","volume":"48","author":"JR Andrews","year":"2020","unstructured":"Andrews JR, et al. Outcomes after ulnar collateral ligament revision reconstruction in baseball players. Am J Sports Med. 2020;48:3359\u201364.","journal-title":"Am J Sports Med"},{"key":"1499_CR19","doi-asserted-by":"publisher","first-page":"3107","DOI":"10.1177\/0363546519876305","volume":"47","author":"A Chauhan","year":"2019","unstructured":"Chauhan A, et al. Nonoperative treatment of elbow ulnar collateral ligament injuries with and without Platelet-Rich plasma in professional baseball players: a comparative and matched cohort analysis. Am J Sports Med. 2019;47:3107\u201319.","journal-title":"Am J Sports Med"},{"key":"1499_CR20","doi-asserted-by":"publisher","first-page":"1926","DOI":"10.1177\/0363546506290988","volume":"34","author":"CC Dodson","year":"2006","unstructured":"Dodson CC, et al. Medial ulnar collateral ligament reconstruction of the elbow in throwing athletes. Am J Sports Med. 2006;34:1926\u201332.","journal-title":"Am J Sports Med"},{"key":"1499_CR21","doi-asserted-by":"publisher","first-page":"536","DOI":"10.1177\/0363546513510890","volume":"42","author":"BJ Erickson","year":"2014","unstructured":"Erickson BJ, et al. Rate of return to pitching and performance after Tommy John surgery in major league baseball pitchers. Am J Sports Med. 2014;42:536\u201343.","journal-title":"Am J Sports Med"},{"key":"1499_CR22","doi-asserted-by":"publisher","first-page":"1783","DOI":"10.1177\/0363546517699832","volume":"45","author":"SJ Frangiamore","year":"2017","unstructured":"Frangiamore SJ, et al. Magnetic resonance imaging predictors of failure in the nonoperative management of ulnar collateral ligament injuries in professional baseball pitchers. Am J Sports Med. 2017;45:1783\u20139.","journal-title":"Am J Sports Med"},{"key":"1499_CR23","doi-asserted-by":"publisher","first-page":"880","DOI":"10.1177\/0363546513519072","volume":"42","author":"JJ Jiang","year":"2014","unstructured":"Jiang JJ, Leland JM. Analysis of pitching velocity in major league baseball players before and after ulnar collateral ligament reconstruction. Am J Sports Med. 2014;42:880\u20135.","journal-title":"Am J Sports Med"},{"key":"1499_CR24","doi-asserted-by":"publisher","DOI":"10.1177\/2325967118808782","volume":"6","author":"RA Keller","year":"2018","unstructured":"Keller RA, et al. Medial elbow pain during the return-to-throwing period after ulnar collateral ligament reconstruction in pitchers. Orthop J Sports Med. 2018;6:2325967118808782.","journal-title":"Orthop J Sports Med"},{"key":"1499_CR25","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1002\/jrsm.1411","volume":"12","author":"LA McGuinness","year":"2021","unstructured":"McGuinness LA, Higgins JPT. Risk-of-bias visualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021;12:55\u201361.","journal-title":"Res Synth Methods"},{"key":"1499_CR26","doi-asserted-by":"publisher","first-page":"2142","DOI":"10.1177\/0363546518773314","volume":"46","author":"SF DeFroda","year":"2018","unstructured":"DeFroda SF, Goodman AD, Gil JA, Owens BD. Epidemiology of elbow ulnar collateral ligament injuries among baseball players: National collegiate athletic association injury surveillance program, 2009\u20132010 through 2013\u20132014. Am J Sports Med. 2018;46:2142\u20137.","journal-title":"Am J Sports Med"},{"key":"1499_CR27","doi-asserted-by":"publisher","first-page":"194","DOI":"10.1016\/j.jor.2025.05.003","volume":"64","author":"OC Sax","year":"2025","unstructured":"Sax OC, et al. Return to play and performance metrics following ulnar collateral ligament reconstruction in major league baseball pitchers. J Orthop. 2025;64:194\u20138.","journal-title":"J Orthop"},{"key":"1499_CR28","doi-asserted-by":"publisher","first-page":"343","DOI":"10.1016\/j.arthro.2024.03.017","volume":"41","author":"SP Fucaloro","year":"2025","unstructured":"Fucaloro SP, Kang AS, Bragg JT, Krivicich L, Salzler MJ. Return to sport after ulnar collateral ligament tears treated with Platelet-Rich plasma injections is influenced by length of rehabilitation and leukocyte content of injections: a systematic review. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2025;41:343\u201356.","journal-title":"Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc"},{"key":"1499_CR29","doi-asserted-by":"publisher","first-page":"442","DOI":"10.1007\/s12178-020-09637-9","volume":"13","author":"JM Apostolakos","year":"2020","unstructured":"Apostolakos JM, et al. The role of biologic agents in the non-operative management of elbow ulnar collateral ligament injuries. Curr Rev Musculoskelet Med. 2020;13:442\u20138.","journal-title":"Curr Rev Musculoskelet Med"},{"key":"1499_CR30","doi-asserted-by":"publisher","first-page":"349","DOI":"10.1007\/s12178-020-09618-y","volume":"13","author":"AR Jensen","year":"2020","unstructured":"Jensen AR, LaPrade MD, Turner TW, Dines JS, Camp CL. The history and evolution of elbow medial ulnar collateral ligament reconstruction: from Tommy John to 2020. Curr Rev Musculoskelet Med. 2020;13:349\u201360.","journal-title":"Curr Rev Musculoskelet Med"},{"key":"1499_CR31","doi-asserted-by":"publisher","DOI":"10.1177\/2325967120966310","volume":"8","author":"SJ Thomas","year":"2020","unstructured":"Thomas SJ, et al. Return-to-play and competitive outcomes after ulnar collateral ligament reconstruction among baseball players: a systematic review. Orthop J Sports Med. 2020;8:2325967120966310.","journal-title":"Orthop J Sports Med"},{"key":"1499_CR32","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1177\/03635465251314054","volume":"53","author":"JR Dugas","year":"2025","unstructured":"Dugas JR, et al. Clinical outcomes of ulnar collateral ligament repair with internal Brace versus ulnar collateral ligament reconstruction in competitive athletes. Am J Sports Med. 2025;53:525\u201336.","journal-title":"Am J Sports Med"},{"key":"1499_CR33","doi-asserted-by":"publisher","first-page":"1208","DOI":"10.26603\/001c.39614","volume":"17","author":"KE Wilk","year":"2022","unstructured":"Wilk KE, et al. The use of the internal Brace to repair the UCL injury of the elbow in athletes. Int J Sports Phys Ther. 2022;17:1208\u201318.","journal-title":"Int J Sports Phys Ther"},{"key":"1499_CR34","doi-asserted-by":"publisher","first-page":"196","DOI":"10.1007\/s11031-013-9389-7","volume":"38","author":"MH White","year":"2014","unstructured":"White MH, Sheldon KM. The contract year syndrome in the NBA and MLB: a classic undermining pattern. Motiv Emot. 2014;38:196\u2013205.","journal-title":"Motiv Emot"},{"key":"1499_CR35","doi-asserted-by":"publisher","first-page":"1355","DOI":"10.1177\/0363546520934778","volume":"49","author":"CJ Hadley","year":"2021","unstructured":"Hadley CJ, et al. Ulnar collateral ligament reconstruction in adolescents: a systematic review. Am J Sports Med. 2021;49:1355\u201362.","journal-title":"Am J Sports Med"},{"key":"1499_CR36","doi-asserted-by":"publisher","DOI":"10.1177\/23259671221125746","volume":"10","author":"AZ Chen","year":"2022","unstructured":"Chen AZ, et al. Psychological factors associated with return to play after ulnar collateral ligament reconstruction: a systematic review. Orthop J Sports Med. 2022;10:23259671221125746.","journal-title":"Orthop J Sports Med"}],"container-title":["BMC Sports Science, Medicine and Rehabilitation"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13102-025-01499-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13102-025-01499-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13102-025-01499-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T15:50:28Z","timestamp":1781625028000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s13102-025-01499-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,27]]},"references-count":36,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["1499"],"URL":"https:\/\/doi.org\/10.1186\/s13102-025-01499-3","relation":{},"ISSN":["2052-1847"],"issn-type":[{"value":"2052-1847","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,27]]},"assertion":[{"value":"14 September 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 December 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"27 December 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable. This study is a systematic review of previously published literature and does not involve human participants, animal experiments, or individual patient data; therefore, formal ethics approval and informed consent were not required.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable. This manuscript does not contain any individual person\u2019s data in any form (including individual images or videos), so consent for publication is not required.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"38"}}