Introduction
- E. Lyle Cain, MD
Epidemiology
- •
Most common in young amateur or professional athletes, ages 15 to 40 years
- •
Most common in males, with 9 : 1 ratio male : female
- •
Most common in baseball, with occasional occurrence in other overhead sports (football, javelin throwing, softball, tennis, wrestling, soccer, gymnastics, cheerleading, and pole vaulting)
- •
Baseball pitchers make up 89%, followed by catchers
- •
Incidence evenly distributed among high school, collegiate, and professional levels
- •
Incidence of UCL injury requiring surgery in high school and adolescent athletes has risen dramatically in the past 5 years.
Pathophysiology
Intrinsic, Extrinsic, and Traumatic Factors
- •
Injury generally occurs during the acceleration phase of the throwing motion ( Figure 11-1 ).
FIGURE 11-1
Phases of the overhead throwing motion.
- •
Biomechanical factors resulting in poor power transfer from the trunk to the arm may predispose the athlete to UCL injury.
- •
Based on cadaveric testing, UCL tensile failure is approached with every throw, especially in high-velocity throwers.
- •
Overuse-type throwing habits result in repeated microtrauma to the static restraints of the throwing elbow, without adequate time for healing.
- •
Accumulation of elbow microtrauma causes the UCL to become weakened and prone to catastrophic failure.
- •
The failure process is exacerbated by high pitch velocity, the throwing of breaking pitches, and inadequate warm-ups.
Classic Pathological Findings
- •
Anterior bundle of the ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow during functional range of motion between 20° and 120° of flexion.
- •
Dr. Frank Jobe pioneered surgical reconstruction of the UCL in 1974, often referred to as “Tommy John Surgery” in reference to the first recipient of the reconstruction procedure.
Clinical Presentation and Examination
- •
All patients report elbow pain while athletically active (throwing, tennis).
- •
Baseball players primarily (96%) complained of pain during the late cocking and acceleration phase of throwing.
- •
Half report an acute onset of pain at the medial elbow, whereas half cannot identify a single inciting event.
- •
For those athletes who can identify the onset of symptoms, three out of four report that the onset occurred during a game, 10% during practice, 10% during the preseason, 4% during the off-season, and 1% while playing recreationally.
- •
Decreased velocity and/or loss of control is a common complaint.
Abnormal Findings
- •
The primary exam finding is tenderness to palpation of the anterior band of the UCL.
- •
Pain with valgus stress (milking maneuver) and active valgus stress are common.
- •
Preoperatively one in four athletes has neurological symptoms, most commonly intermittent paresthesias in the ulnar nerve distribution (ring and small fingers) during throwing.
Pertinent Normal Findings
- •
Elbow range of motion is generally full, although many overhead athletes have a flexion contracture of about 5°.
- •
Only one in four patients demonstrates valgus instability to manual testing at 30° elbow flexion.
Imaging Studies
- •
Radiographic examination is normal in half, whereas half have assorted radiographic abnormalities, most commonly olecranon osteophyte formation and ectopic calcification within the UCL substance.
- •
Magnetic resonance arthrography (MRA) with intraarticular contrast is the gold standard diagnostic test.
- •
MRA may show complete tearing or a partial undersurface tear of the anterior band of the UCL.
- •
CT arthrogram is useful in patients who cannot undergo MRA
- •
Ultrasound may be useful in diagnosis and may be helpful to allow some level of reparative process of the ligament with nonsurgical treatment.
Differential Diagnosis
- •
Flexor pronator tendinitis: tenderness anterior to the UCL along the medial epicondyle, pain with resisted wrist pronation
- •
Ulnar neuritis: sensory disturbance to the ring and small fingers, positive Tinel’s at the cubital tunnel, normal imaging
- •
Olecranon osteophyte/valgus extension overload: posterior medial pain along the olecranon tip with extension, pain during ball release or follow-through, osteophyte on radiographs
Treatment
Nonsurgical Options
- •
Rest: cessation from throwing or any valgus producing stress to the elbow
- •
NSAIDs
- •
Physical therapy to maintain elbow motion, decrease pain, strengthen both the shoulder and elbow musculature
- •
Injection of corticosteroids or platelet rich plasma: controversial
Guidelines for Choosing among the Nonsurgical Treatment Options
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Level of play: Higher level of play (major league) is more likely to have successful outcomes than lower level (high school, recreational).
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Degree of injury (partial vs. complete): Complete tears are more likely to lead to chronic symptoms.
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Timing of season: Return to play generally takes approximately 1 year.
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Position (pitcher vs. fielder): Pitcher and catcher require more elbow endurance, and may take longer to return after surgery.
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Acute versus chronic injury: Chronic ligament insufficiency is less likely to respond favorably to nonsurgical treatment.
- •
Symptom magnitude: Some athletes can participate at various levels (i.e., fielding but not pitching) despite ligament damage.
Surgical Indications
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Absolute: complete tear in pitcher who has failed nonoperative treatment and is unable to participate at the desired level of play
- •
Relative: any degree of tear in any sport or position that is unable to return to the desired level of competition after appropriate nonsurgical treatment, and is willing to participate in a minimum 1 year rehabilitation period
- •
Most UCL injuries in nonoverhead athletes (e.g., football, gymnastics, soccer) do not require surgery for continued participation.
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
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Age
- •
Level of play
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Degree of injury (partial vs. complete)
- •
Timing of season
- •
Position (pitcher vs. fielder)
- •
Acute versus chronic injury
- •
Symptom magnitude
Aspects of Clinical Decision Making When Surgery Is Indicated
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Graft choice: palmaris longus versus gracilis tendon (autografts)
- •
Additional procedures as indicated: ulnar nerve transposition, olecranon osteophyte excision, loose body removal
- •
Muscle-splitting versus modified Jobe (muscle elevation)
- •
Graft fixation: suture fixation versus interference screw versus docking
Evidence
Multiple Choice Questions
- QUESTION 1.
During which phase of the throwing motion do symptoms most commonly occur with UCL injury?
- A.
Wind-up
- B.
Acceleration
- C.
Ball release
- D.
Follow-through
- A.
- QUESTION 2.
What position in baseball most commonly injures the UCL?
- A.
Catcher
- B.
Infield
- C.
Outfield
- D.
Pitcher
- A.
- QUESTION 3.
What is the most common physical exam finding with UCL injury?
- A.
Pain with resisted pronation
- B.
Positive Tinel’s at the cubital tunnel
- C.
Pain with valgus stress
- D.
Loss of motion
- A.
- QUESTION 4.
What percentage of athletes is expected to return to the same level or higher competition after UCL reconstruction?
- A.
Less than 25%
- B.
25% to 50%
- C.
50% to 75%
- D.
Greater than 75%
- A.
- QUESTION 5.
What is the gold standard diagnostic test for UCL injury?
- A.
Plain radiographs
- B.
CT scan
- C.
Ultrasound
- D.
Arthrogram MRI
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Clinical Presentation)
- QUESTION 2.
Correct answer: D (see Epidemiology )
- QUESTION 3.
Correct answer: C (see Clinical Presentation)
- QUESTION 4.
Correct answer: D (see Evidence )
- QUESTION 5.
Correct answer: D (see Imaging Studies )
Nonoperative Rehabilitation of Ulnar Collateral Ligament Injuries
- E. Lyle Cain, MD
- Kevin E. Wilk, PT, DPT
- Todd R. Hooks, PT, OCS, SCS, ATC, MOMT, MTC, CSCS, FAAOMPT
- Kevin E. Wilk, PT, DPT
- •
Restrict elbow range of motion and valgus forces during the early phases of treatment to minimize stresses upon healing structures.
- •
Conduct a proper assessment and institute a proper rehabilitation of the entire kinetic chain to reduce the valgus stresses imparted upon the elbow during overhead athletics.
- •
Ensure an appropriate functional interval return to play program is implemented to allow for a controlled progression into sporting activities.
- •
Proper communication between coach, player, physician, and clinician to determine appropriate return to play guidelines based upon sport of the athlete.
Phase I (Immediately following injury through week 2)
Protection
- •
A hinged elbow brace is used to restrict motion and prevent valgus strain.
- •
The athlete is allowed to perform personal care ADLs while wearing brace.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 3 to 10) | PHASE III (weeks 10 to 14) | PHASE IV (weeks 14 to 18) |
|---|---|---|---|
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