A qualitative assessment of return to sport following ulnar collateral ligament reconstruction in baseball players

Abstract

Background

The rate of ulnar collateral ligament (UCL) reconstruction has been increasing at all levels of play. With excellent outcomes, primary UCL reconstruction has allowed many overhead athletes to return to their pre-injury sport. However, the subjective factors influencing this decision to return to sport have yet to be studied. The aim of this study is to understand the factors influencing an athlete's decision to return to pre-injury level of sport after primary UCL reconstruction.

Methods

An experienced interviewer conducted qualitative, semi-structured interviews of patients aged 18–35 years who had undergone primary UCL reconstruction by one fellowship-trained, Major League Baseball (MLB) team orthopaedic surgeon. All subjects were throwing athletes prior to injury and had a minimum two-year follow-up without revisions. Qualitative analysis was then performed to derive codes, categories, and themes. Patients were surveyed to assess familiarity with UCL reconstruction as well as to obtain Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) highlighting current activity and function levels along with sport participation.

Results

Twenty-two athletes were interviewed to elucidate four predominant themes influencing their return to sport: trust in surgeon and care team, innate drive and optimism, misconceptions regarding post-operative athletic ability, and life priorities. A significant difference was noted between patients that returned and those that did not in the KJOC survey and for the statement that UCL reconstruction surgery would improve throwing ability relative to patients’ peak performance three years prior to the surgery. Athletes who did not return to sport cited lifestyle changes and age as limiting factors.

Conclusion

Patients' decision to return to their pre-injury level of sport after primary UCL reconstruction was based on trust in their care team's reputation, intrinsic personality traits, anecdotal evidence about post-operative outcomes, and lifestyle. This study emphasizes the importance for health care providers to educate patients toward realistic expectations upon return to sport. On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport.

Level of evidence

Level IV.

1. Introduction

Ulnar collateral ligament (UCL) injuries most frequently occur due to repetitive stress from overhead movement in sports like baseball, volleyball, and javelin throwing.¹¹ In 1974, Dr. Frank Jobe performed the first UCL reconstruction and changed the paradigm with regard to UCL injuries.⁴⁹ Since that time, Dr. Jobe's technique and subsequent derivatives like the docking technique and modified-Jobe technique have been used with increasing frequency.²² A 2015 survey of Major League Baseball (MLB) pitchers revealed 25% of pitchers had undergone UCL reconstruction surgery.¹³ With the growing rate of UCL injuries and UCL reconstruction over the past two decades in baseball players ranging from youth to professional levels, interest has increased with regard to return to sport after UCL reconstruction surgery.^24,27,30,58

There is a notable disparity among studies relating to pre and post-operative athletic ability following UCL reconstruction. Some studies declaring that ability increases or is similar after the surgery only assess statistics relative to the year before a player gets UCL surgery, and it has been shown that overhead athletic ability typically reaches a trough in the year before a player undergoes a UCL surgery.^23,31,32 Other studies that factor in players' statistics from more than a year before UCL reconstruction report decreased performance and slower fastball speeds after the procedure.^{16,32,33,36,45} Questionnaires have been used to investigate perception of UCL reconstruction by players, parents, coaches, and the media. Notably, greater than 25% of each category, including 51% of high school players, believed that UCL reconstruction can enhance performance in players without elbow injury, and over 20% of players and media members thought the surgery can enhance athletic ability beyond pre-injury peak performance in athletes that sustained UCL injuries.^1,14 The high return to sport rates seen following UCL reconstruction, ranging from 79 to 87%,^{11,16,22,23,36,44,45} relative to other surgeries^5,55 may be influenced by misconceptions of improved athletic ability post-operatively. Another contributing factor in return to sport is the psychological response of athletes to injury. Negative psychological responses such as frustration, depression, and fear are natural parts of injury; however, studies have demonstrated that the persistence of these emotions and maladaptive coping strategies predict worse outcomes of rehabilitation, recovery, and reinjury anxiety ultimately affecting a patient's decision to return to sport.^{4,12,15,50,52,57} Contrarily, motivation, self-efficacy, and social support have been described as positive factors influencing post-operative return to sport.^20,47,54, 55, 56

While quantitative research surrounding UCL reconstruction and return to sport in baseball players has been growing, the subjective intrinsic and extrinsic motivational factors influencing a player's decision to return to baseball after surgery have not yet been explored. Because return to sport is a primary criterion on which a successful outcome from surgical treatment is frequently judged, it is beneficial to understand the qualitative factors affecting a baseball player along with players' psychological responses. As such, the primary goal of this study was to understand the specific factors influencing a patient's decision to return to sport after UCL reconstruction.

2. Materials and methods

2.1. Participants

Consenting patients between 18 and 35 years of age who had undergone primary, unilateral UCL reconstruction by one fellowship-trained, MLB team orthopaedic surgeon between 2011 and 2017 at a single university-affiliated hospital were included in the study. All subjects were throwing athletes prior to injury and had a minimum two-year follow-up without revisions. Patients with any need for further surgery or those who had been treated more than eight years ago were excluded from the study and considered ineligible to limit confounding factors and recall bias. Approval from the university's Institutional Review Board (protocol number: STU00206580-MOD0004) was granted before study commencement.

2.2. Recruitment and data collection

Recruitment was performed in two phases. Eligible patients were initially contacted by mail or email. This was followed by a telephone inquiry. Informed consent was then obtained, and interviews were scheduled. Audio-recorded telephone interviews lasting 30–45 min were conducted by a single, trained interviewer (M.P.M.) using a study-specific question guide. The open-ended questions in the guide were derived from a review of return to sport literature, qualitative studies pertaining to sports injury, sports medicine, and psychology.^7,46, 47, 48^,54, 55, 56 The interviewer utilized the method of active passivity,³⁷ avoiding interrupting patients unless the discussion deviated significantly from the aim of the interview. Anonymity was preserved during interview transcription by using an alphanumeric identifier for each patient.

The semi-structured interviews elucidated patient-derived concepts and themes regarding the decision to return to sport after UCL reconstruction. The interviewer employed an iterative approach to the question guide, creating more targeted questions which allowed patients to express their thoughts more thoroughly along with giving the interviewer freedom to probe deeper into a patient's response. This method allowed more detailed data to be collected from each interview than would otherwise have been obtained using solely quantitative methods.

As a supplement to the interviews, Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as well as a survey regarding patient familiarity with UCL reconstruction were obtained as secondary outcome measures. The UCL reconstruction familiarity survey was formatted with statements that patients could either strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree with using a scale of 1–5, respectively, based on the information they had prior to being educated by their healthcare team. The validated patient-reported outcome measures along with the UCL familiarity survey created by the research team were administered and collected using the REDCap electronic data capture tool.²⁸

2.3. Data analysis

Sport participation was defined by three categories: type of sport, level of competition (recreational, varsity college/university, professional), and frequency of activity. Only those patients who had identical pre-injury and current values in all three categories were classified as having successfully returned to their pre-injury level of play. Patients who did not return to sport were defined as never having achieved an equivalent status as described above at any time after their surgery. The sample size for each group was determined once data saturation was obtained (i.e., data collection was terminated after no new themes, concepts, or explanations emerged from subsequent interviews).³⁹

Three members of the research team (M.P.M., V.K.T., J.G.P.) applied the method used by Strauss and Corbin⁵³ of open coding, axial coding, and selective coding to each of the transcribed interviews.³⁴ Using a bottom-up approach, line-by-line coding of the data was grouped into commonalities that reflected categories. Connections were then drawn between these categories to classify them as broader themes. These themes became the overarching, patient-derived explanations for the factors influencing a patient's decision to return to sport following UCL reconstruction. Secondary outcome measures were statistically analyzed using Welch's t-test. Normally distributed continuous variables were reported as mean ± standard deviation. Results considered statistically significant were those with a p value less than 0.05.

3. Results

A total of 52 patients met the inclusion criteria for this study. No patients declined participation; however, 30 patients were unable to be contacted. Data saturation was reached after 22 patients were interviewed: 18 (82%) returned to pre-injury level of sport while four (18%) did not according to the three criteria mentioned prior (i.e., type of sport, level of competition, and frequency of activity). As outlined in Table 1, no statistically significant difference was measured between mean age, length of post-operation recovery, or time elapsed since surgery between the group that returned to sport and the group that did not. Study participation and patient demographics are outlined in Fig. 1 and Table 1, respectively.

Table 1.

Patient Demographics. Data are reported as n (%) or as mean ± SD with p value calculated using Welch's t-test. Abbreviations: y is year(s), no. is number, mo is month(s).

CHARACTERISTIC	PATIENTS WHO RETURNED TO PRE-INJURY SPORT	PATIENTS WHO DID NOT RETURN TO PRE-INJURY SPORT	p value
Age, y	25.28 ± 3.46	25 ± 1.83	0.88
Age group, no. of patients
18-25 y	10 (56)	2 (50)
26-35 y	8 (44)	2 (50)
Sex
Male	18 (100)	4 (100)
Female	0 (0)	0 (0)
Level of Competition
Recreational	0 (0)	0 (0)
Varsity	6 (33)	1 (25)
Professional	12 (67)	3 (75)
Position
Pitcher	15 (83)	4 (100)
Position Players	3 (17)	0 (0)
Length of post-operation recovery, mo	9.53 ± 2.20	9.5 ± 3.32	0.98
Time since surgery, mo	56.28 ± 21.39	50.75 ± 10.53	0.62

Fig. 1.

Study participation. *Incorrect contact information or no answer after repeated calls/messages/emails. **Identical sport, level of competition, and frequency of activity.

3.1. Patient-derived themes

After achieving data saturation, four distinct themes highlighting the motivators that encouraged or discouraged patients’ return to sport were distilled: trust in care team, individual personality, anecdotal evidence, and priorities. Table 2 lists patient quotations referenced in the following subsections.

Table 2.

Player Quotations. Letter/Number combination indicates unique patient identifier.

THEME	QUOTATION
Trust in Care Team	“I knew I would be all right getting back on the mound because I had the surgeon for [an MLB team] taking care of me, and I was just following his program” (A15) “You just have to trust the process when you are being taken care of by one of the best” (A7) “Your arm feels different after the surgery, and you are scared you will get hurt again. I knew I was with some of the best physical therapists out there though, so I had faith in them, and they were always encouraging me to trust my arm” (A4) “My surgeon was great about answering my questions, and I knew he would tell me if he felt like I was not ready to return” (A1) “My [physical] therapists were the people I could trust to tell me if I was not going hard enough or if I was pushing myself too much” (A12)
Individual Personality	“I felt like I needed to win rehab and was always comparing myself to the guys next to me to get back better and quicker than they did” (A6) “I was driven every day of rehab to grind because setbacks do not define me, and that is who I am as an athlete” (A14) “Rehab is a rollercoaster of emotions with daily highs and lows, but you have to accept it, make a plan, follow it, and stay tough through it” (A16) “Rehab is grueling, and you can't lose sight of the daily little picture for the big picture end goal, or you'll just quit” (B3) “I felt like I could see the silver lining to my situation every day” (A12) “I am a glass-half-full person” (A17) “I stay positive and put in the work to make sure things work out” (A16) “My family was great, but I really relied on myself to get through it” (A2) “I had everyone backing me, but I was the one who drove myself to get better” (A18) “I left school to do my rehab because I just needed to get better by myself” (A1)
Anecdotal Evidence	“I knew a bunch of guys that had the surgery and came back with better control and velocity” (A17) “I knew it was not a guarantee, but my older brother had the surgery and came out of rehab at the top of his game” (A12) “You are like an old truck with a new engine after the surgery—you have a lot of experience, and now, you have a better arm” (A2) “The doctors tell you all the statistics, but everyone is still convinced they will get at least a 2-3mph increase in velocity after surgery” (A13) “You see everyone else come back better, so you would never think you will be the exception to the rule” (A6) “If you listen to coaches and other guys talk, it sounds like it is no big deal to get the surgery” (B2) “Based on what you see in the media and around you at training camp, you are expected to come back after the surgery” (A12)
Priorities	“The minors do not pay the bills and come with no guarantees. I just wanted to get the surgery and go back to school so I could get a job to support my family” (B1) “I was at a point where I wanted to start a family with my wife, and I needed to go back to school so I could land a job with a stable salary” (B2) “At a certain age, you ask yourself if you think you are good enough to keep playing the game. You have to be honest with yourself and ask if it is worth it versus pursuing something else that interests you” (B4) “I am not married, and I do not have any kids, so there was nothing holding me back from the sport I love” (A10) “I just wanted to get back to the game … I only feel like myself when I am on the mound” (A15) “I do not know what I would have done with myself if I had not kept playing” (A7)

3.2. Trust in care team

Players unanimously identified trust in their care team, specifically emphasizing the role of their surgeon and physical therapists, as a key factor positively influencing their decision to return to play. They placed large emphasis on surgeon reputation instilling confidence in returning to sport (A15, A7). Players mentioned transient feelings of fear of reinjury during the rehabilitation period; however, these emotions dissipated due to players’ relationships with their physical therapists (A4). Three players mentioned they switched physical therapist companies because they did not trust the quality of the care team. Many patients also cited how critical it was for them to feel like the care team was being honest with them about their progress in recovery and their efforts in rehabilitation (A1, A12).

3.3. Individual personality

Another core element identified among players in their decision to return to playing was their individual personalities. Players commonly referred to themselves as “resilient” (A3), “self-motivated” (A4), and “Type A with a mind over matter attitude” (A10). Many players mentioned their competitive athlete mindset driving them to overcome any obstacles or setbacks and pushing them forward in rehabilitation to their goal of playing again (A6, A14). They discussed how their focus on achieving daily milestones, setting priorities and adhering strictly to them, was crucial in coping during rehabilitation (A16, B3). Players also commonly identified optimism as a vital component of their personalities that drove them to return to playing (A12, A17, A16). While some players identified support from their families and teammates as important factors, many players classified external support as secondary to relying on themselves and their individual drive (A2, A18, A1).

3.4. Anecdotal evidence

Players often cited anecdotal evidence from other teammates or coaches about post-surgical results of increased control and velocity following UCL reconstruction that influenced their decision to return to playing (A17, A12, A2). Although patients felt adequately informed by their medical care team about the possible outcomes of the procedure, many still were convinced they personally would have positive post-surgical results (A13). They felt it was the exception to the rule to have decreased control or velocity following the procedure (A6). Players frequently remarked that the media and others in baseball normalize UCL reconstruction as a procedure that everyone in the sport gets at some point (B2, A12). Many players were even surprised to consider reasons why players would not return to playing after having UCL reconstruction.

3.5. Priorities

Shifting priorities, especially in terms of family commitments and occupation opportunities, was principally identified as motivation for patients that did not return to sport. Two athletes mentioned requiring stability in terms of career and salary to support their families (B1, B2). One athlete just felt like he had aged out of the sport and wanted to pursue other interests (B4). Patients who returned to sport also cited their priorities as a motivating factor. These players identified baseball as simply the largest priority in their lives with nothing else competing for their attention (A10, A15, A7).

3.6. Secondary outcomes

Table 3 summarizes secondary outcome measures and shows a statistically significant difference in patient-reported mean KJOC scores (79.11 in those that returned compared to 51.75 in those that did not; p = 0.04). There were also significant differences noted in the UCL reconstruction familiarity survey regarding patient understanding of the risks, benefits, and consequences of UCL reconstruction surgery (4.39 in those that returned compared to 2.75 in those that did not) and the belief that UCL reconstruction surgery would improve throwing ability relative to patients’ peak performance three years prior to the surgery (3.83 in those that returned compared to 2.25 in those that did not). Notably, a majority of players indicated that they either “agreed” or “strongly agreed” with the belief that the surgery would give them superior post-operative athletic ability statements compared to three years and one year prior to surgery.

Table 3.

Summary of Secondary Outcomes. Data are reported as mean ± SD with p value calculated using Welch's t-test.

	PATIENTS WHO RETURNED TO PRE-INJURY SPORT	PATIENTS WHO DID NOT RETURN TO PRE-INJURY SPORT	p value
WOMAC	6.33 ± 10.14	8.5 ± 7.72	0.69
ASES	95.26 ± 9.90	92.05 ± 9.20	0.56
KJOC	79.11 ± 21.65	51.75 ± 24.96	0.04
UCL Reconstruction Familiarity: 1–5 (Strongly Disagree-Strongly Agree)LikertScale
I believed a UCL injury would have a significant impact on my daily activities (e.g., cooking, bathing, eating).	3 ± 1.53	3 ± 1.83
I believed a UCL injury would have a significant impact on my athletic performance.	4.28 ± 0.75	4.25 ± 0.96
I understood the risks, benefits, and consequences of UCL reconstruction surgery.	4.39 ± 0.78	2.75 ± 2.06
I believed a UCL reconstruction surgery was a risky procedure.	2.44 ± 1.25	3.5 ± 1.29
I believed UCL reconstruction surgery would have a large impact on my level of athletic play.	4 ± 1.03	3.25 ± 1.71
I believed UCL reconstruction surgery would make me better at throwing compared to my peak performance in the 3 years before my surgery.	3.83 ± 1.10	2.25 ± 0.96
I believed UCL reconstruction surgery would make me better at throwing compared to my peak performance in the year before my surgery.	4 ± 0.84	3 ± 1.83
I believed that undergoing UCL reconstruction surgery earlier when you're not injured limits the need for UCL reconstruction surgery later in life.	1.94 ± 1.30	1.5 ± 0.58
I was planning to return to sport post-surgery.	4.89 ± 0.47	4.25 ± 1.5

4. Discussion

The four themes—trust in care team, individual personality, anecdotal evidence, and priorities—elucidated by this study influenced players to return to sport following primary UCL reconstruction. Priorities was the key theme that emerged motivating players not to return to sport following surgery.

4.1. Trust in care team

The most influential factor listed unanimously by surveyed patients in their decision to return to sport was trust in their care team and its reputation. Players specifically emphasized the role their surgeon and physical therapists had in making them feel mentally and physically ready to return to play. Bejar et al.⁸ demonstrated that athletes' motivation during sport injury rehabilitation was largely influenced by the degree to which they perceived that athletic trainers established rapport, demonstrated competence, and solicited input from the athlete to involve them in their care. Arvinen-Barrow et al.⁶ also showed the importance of sports medicine professionals in addressing the psychosocial aspects of rehabilitation. Athletes believed that open and honest communication from their care teams was vital for recovery and confidence in returning to full fitness. A study assessing return to sport after hip arthroscopy reported that patients' relationships with healthcare providers was a critical external influence on those that returned to sport. Physical therapists and surgical teams were credited for supportive recoveries and transitions to sport with patients stating that trust in their care team made them feel confident in taking steps to return to play.⁵⁴ Another study indicated that some athletes did not return to sport because their surgeon advised them not to, emphasizing the important role the care team holds in a patient's decision to return to play.⁵⁶

The role of trust in the care team is so significant in this study that it overwhelmed a motive that patients commonly cite as a reason they decide not to return to play: fear of reinjury.^2,3,38,40,54, 55, 56 Players mentioned they transiently had kinesiophobia during rehabilitation, but their physical therapists and surgical team helped assuage these fears. A survey of sports medicine physicians showed that fear of reinjury is one of the most discussed topics between physicians and patient-athletes; however, it also highlighted that orthopaedic surgeons reported the lowest frequency of noninjury-related psychological discussions compared with other physicians.³⁸ Compared with athletes who have undergone ACL reconstruction^3,40,56 or Bankart repair,⁵⁵ fear of reinjury was a far less prevalent theme in this study's patient population.

4.2. Individual personality

Players’ intrinsic personality traits were strong motivating factors in the decision to return to sport. The athletes in this study described a competitive mindset and self-motivation as key components of their personality, falling under the broader theme of self-efficacy. This corresponds with athletes in other studies citing self-efficacy as a critical element in achieving post-operative sport goals after ACL reconstruction, shoulder stabilization, major athletic injury, and even adherence to rehabilitation.^9,18,25,26 Christino et al.¹² showed that self-efficacy can have as significant an impact as knee stability on return to sport following ACL reconstruction. Lyngcoln et al.³⁵ found self-motivation to be the single most important psychological factor influencing exercise adherence post-operatively in patients undergoing rehabilitation after ACL reconstruction. Everhart et al.²⁵ further supported this idea by showing that measures of self-efficacy, self-motivation, and optimism were predictive of rehabilitation compliance, return to sport, and self-reported symptoms. Along with self-efficacy, optimism was an essential element for athletes in this study. They displayed active coping skills in their ability to focus on setting goals, asking for help, and seeking solutions to their problems. One study found that strong optimism was common in patients that returned to sport following hip arthroscopy and that these patients scored highly on the active coping portion of the Brief COPE survey with corresponding adaptive coping mechanisms.⁵⁴ Flanigan et al.²⁶ described a positive correlation between orthopaedic surgical outcomes and psychological traits such as self-confidence, optimism, and motivation to recover from injury.

Interestingly, players in this study reported they primarily relied on themselves, with one athlete even stating that he specifically preferred isolation, rather than requiring a strong social support system to help them through the post-operative process and rehabilitation. This is contrary to what much of the literature emphasizes in that social support is critical for a player's emotional stability and coping following an injury.^{10,17,41,46,54,55}

4.3. Anecdotal evidence

One of the most concerning factors influencing the decision to return to sport was anecdotal evidence of success following UCL reconstruction. Patients felt they had been informed by their healthcare team appropriately about the possible outcomes—both beneficial and adverse—of the surgery, but they came into the process with several preconceived notions colored by stories of successful recovery from family, teammates, and the media. Athletes had knowledge of patients that had undergone the surgery with high return to sport performance, so they thought they were essentially guaranteed similar results. Some players can experience an increase in throwing velocity and control likely because they are forced to take time off for rehabilitation, allowing micro-tears and general shoulder and elbow overuse issues to heal.²⁹ Another key factor to the improvement some players see is increased awareness of conditioning and training during the rehabilitation process which was mentioned by multiple athletes interviewed in this study. Rarely do players have such an extended period of time to rest their arm and work on improving throwing mechanics to maintain the longevity of their arm since they start playing baseball as a child. Although surgical success is largely reported in UCL surgery, many baseball players do not realize the disconnect between their version of success—returning to their peak athletic ability—and that of many surgeons—general return to sport.³⁶

Many studies discuss UCL reconstruction as an epidemic driven by misconceptions perpetuated by the media, coaches, teammates, and parents.^{1,13,14,19,21,51} Ahmad et al.¹ administered a questionnaire to 189 players, 15 coaches, and 31 parents to assess public perception regarding UCL reconstruction. The survey results showed that 28% of players and 20% of coaches believed a pitcher's performance would definitively be improved after surgery, and, more strikingly, 26% of college athletes, 30% percent of coaches, 37% of parents, and 51% of high school athletes believed UCL reconstruction should be performed as a prophylactic procedure to enhance performance in an uninjured athlete. This study demonstrates a significantly skewed perspective on the indications and utility of the surgery. While the public perception is that players undergoing UCL reconstruction return with improved performance, this is clearly not always the case. Makhni et al.³⁶ showed there is a decline in performance across several metrics (e.g., earned run average, batting average against, percentage of pitches thrown in the strike zone, innings pitched, average fastball velocity, etc.) after surgery compared with pre-injury levels. However, a study by Mitchell et al.⁴¹ and another by Jiang et al.³³ found that these decrements were not statistically different from comparable declines found in age-matched controls who did not undergo UCL reconstruction surgery.

4.4. Priorities

When considering patients' decisions to return to sport, lifestyle and family situation are often critical factors. Players that did not return to sport wanted to pursue an alternative career or felt they were too old to continue playing. Similar findings were presented in studies on return to sport in patients who underwent arthroscopic Bankart repair and ACL reconstruction.^42,55,56 These studies demonstrated several examples of “family taking priority over sport” and “the idea of aging and moving on to different stages of life”⁵⁶ as influential components in patients' decisions not to return to sport. In the Bankart repair study,⁵⁵ 50% of patients in the 30–40 years old age category that did not return to sport cited “age” as the sole determinant of their decision not to return.

Other players discussed lifestyle as a reason for returning to play. Their lifestyle revolved around baseball as their primary priority, and they had nothing limiting them from pursuing the sport. Podlog et al.⁴⁸ support this finding by highlighting love of competing in a specific sport as a key motive for players to return to sport following serious injury. Tjong et al.⁵⁶ found that these patients tend to be younger with fewer conflicting commitments. However, the current study indicates no statistically significant difference in age between the groups that did and did not return to sport.

4.5. Secondary outcomes

The expected significant difference between the two groups' current KJOC scores (79.11 returned vs 51.75 did not return; p = 0.04) is notable because it shows that while the patients who did not return to sport mainly attributed their decision to shifting priorities, functional ability may have also played a role. O'Brien et al.⁴³ found that throwing athletes who returned to their previous level of play following UCL reconstruction had a mean KJOC score of 77 which is consistent with this study; however, in that study, those that did not return to play had a mean score of 69 which is higher than what was reported in this study.

The findings of the UCL reconstruction familiarity survey were interesting in showing that patients who did not return to sport felt they did not understand the risks, benefits, and consequences of the surgery as well as those that did return. Although patients unanimously stated they were adequately informed by their healthcare team, this may indicate that the athletes who did not return still felt blindsided by their post-surgical outcome, especially since both groups on average at least agreed with the statement that they were initially planning to return to sport post-surgery. It was also notable that there was a significant difference between the two groups in that players who did not return to sport disagreed with the statement that they believed UCL reconstruction surgery would make them better at throwing compared to their peak performance in the three years before surgery while players who returned were more likely to agree. This finding supports what players reported in the qualitative interviews regarding anecdotal evidence from others about success following UCL reconstruction forming their preconceived notions and influencing their return to sport.

4.6. Limitations

There are caveats to consider when interpreting the findings of this study. The patient population was restricted to one urban, academic orthopaedic surgeon and was associated with possible sampling biases. The study population solely consisted of male baseball players, affecting the applicability of the findings to a broader patient population. Moreover, the patient cohort did not encompass all levels of athletic participation as it consisted of either professional or varsity level baseball players, excluding recreational athletes. By nature of involving interviews, the study lends itself to possible recall bias and social desirability bias as well as responder bias in that patients may not have been entirely forthcoming in explaining their personal motivators despite guaranteed confidentiality. Although the combined qualitative and quantitative nature of this study gave it strength, the limited number of patients required to achieve data saturation using qualitative methods detracts from the statistical significance of the secondary outcome quantitative measures. It also would have improved the study's qualitative and quantitative assessments if the groups were equal in size. Improving on these factors will lead to the development of strategies to help athletes and physicians better understand the patient factors informing return to sport after a serious injury.

5. Conclusions

This study highlights four primary factors motivating baseball players' decisions to return to sport following primary UCL reconstruction surgery: trust in surgeon and care team, intrinsic personality traits, anecdotal evidence about post-operative outcomes, and life priorities. The study emphasizes the importance for healthcare providers to educate patients toward realistic expectations upon return to sport. It also brings to the forefront the idea of assessing a player's mental state as an adjunct to typical athlete post-operative rehabilitation programs. On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport.

CRediT authorship contribution statement

Mitesh P. Mehta: Writing - original draft, Conceptualization, Formal analysis, Visualization, Project administration. Vehniah K. Tjong: Methodology, Resources, Conceptualization, Supervision. Joshua G. Peterson: Investigation, Validation, Writing - original draft. Robert A. Christian: Writing - review & editing, Formal analysis. Stephen M. Gryzlo: Supervision, Investigation, Resources.

Declaration of competing interest

None.