Chapter 45 Ulnar Collateral Ligament Reconstruction

Michael Levinson, PT, CSCS

Injury of the ulnar collateral ligament (UCL) is almost exclusively limited to the competitive throwing population. More specifically, it is most common in baseball players. The UCL of the elbow has been shown to contribute 54% of the resistance to valgus stress while throwing. Injury is a result of the extreme valgus forces placed on the elbow, especially during pitching. Tearing of the UCL can result in pain and instability. Conservative treatment has not been seen to be successful for this injury, especially with pitchers. Continued pitching with this injury can lead to arthritic changes.

To restore stability, a reconstruction is often indicated. The most common graft choice for the reconstruction is the palmaris longus tendon. In the absence of this muscle, the graft is generally taken from the patient’s gracilis. Graft choice does not affect the Hospital for Special Surgery (HSS) guideline. The HSS UCL reconstruction guideline is based on the “docking technique” described by Altchek et al.

Surgical Overview

• A UCL reconstruction, using a palmaris longus tendon graft, is performed using a combination of open and arthroscopic surgery.

• Most commonly, the graft is harvested from the ipsilateral palmaris longus tendon.

• Exposure is created by splitting the flexor carpi ulnaris muscle.

• Bone tunnels are created in the humerus and ulna.

• The graft is “docked” securely into the tunnels, using sutures.

• The elbow is then taken through a full range of motion (ROM) to determine final graft tension and placed in a splint at 60-degree flexion.

Rehabilitation Overview

• The rehabilitation program following UCL reconstruction begins immediately after surgery, with the patient instructed in a home exercise program.

• Formal physical therapy usually does not begin until approximately 4 to 6 weeks post-surgery.

• Care must be taken to protect the graft throughout the progression of the rehabilitation program.

• The program emphasizes early, controlled motion so as to avoid any excessive passive stretching later in the program. This will allow the graft to remain as tight as possible until the patient is allowed to return to activity.

• The program also limits excessive stress to the wrist and elbow during the early phases to allow optimal soft tissue healing.

• Shoulder and scapular strengthening are a key component of the program.

• Following kinetic chain principles, improved proximal strength and efficiency should reduce stress on the elbow.

• The program is based on the patient beginning an interval throwing program at 4 months post-surgery and a hitting program at 5 months.

Postoperative Phase I (Weeks 1 to 4)

GOALS

• Promote healing: reduce pain, inflammation, and swelling

• Begin to restore ROM to 30 to 90 degrees

• Independent home exercise program

PRECAUTIONS

• Brace should be worn at all times

• No PROM of the elbow

TREATMENT STRATEGIES

• Brace set at 30 to 90 degrees of flexion

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