Injuries to the ulnar collateral ligament (UCL) were previously career-ending injuries in high-level pitchers. Since Dr. Frank Jobe first performed ulnar collateral ligament reconstruction (UCLR) in 1974, there have been many variations of the technique which have allowed competitive athletes to return to play at a high level. Although UCLR has shown a high rate of return to play and athlete satisfaction, complications associated with diagnosis, the operation, and recovery can present unique challenges to the treating physician and are important to understand.
Preoperative considerations of athletes who sustain a UCL injury are critical to attaining successful outcomes. Assessing preoperative considerations requires a thorough understanding of patient history and expectations including activity level, primary sport played, future plans of continuing to participate, and level of participation. Gauging expectations for participation and understanding the demands required for a stable elbow in each athlete is the crucial first step in managing UCL injuries and limiting complications.
The increasing popularity of UCLR or “Tommy John” surgery in the popular media and public has led to many patients presenting to the office with preconceived impressions and expectations for what surgeons can offer. A study by Conte et al. evaluating perceptions of the media that cover professional baseball found that about half of respondents knew an elbow injury was a prerequisite for UCLR, 25% believed the indication was to improve performance, and half overestimated the ability to return to play, as well as the ability to return before 1 year after surgery. Public perception is similar to media perception, as Ahmad et al. found that many believed UCLR should be performed on players without an elbow injury to enhance performance, many did not believe number of pitches thrown to be a risk of injury, and many also believed performance would be better than preinjury levels and players would return to sport in less than 9 months. This creates a difficult challenge for the treating physician and is the first obstacle to properly educating our patients with UCL injuries and giving realistic, attainable expectations before treatment.
Basic background information is an important part of the initial patient history. UCL injuries are most frequently seen in overhead athletes, particularly baseball pitchers. Although UCL injuries occur in other athletic populations, it is important to understand the demands placed on the elbow by different sports, as the demand for a stable elbow for a Major League Baseball (MLB) pitcher is much different than for a first baseman and significantly different than for a basketball player. The patient’s current and expected level of play, including recreational, high school, college, or professional level plays a pivotal role because the treatment offered in these populations may differ.
Injury mechanism and acuity of injury should be ascertained as part of the player’s history. Understanding if this is a longstanding problem with the elbow that is now more debilitating will represent a more chronic pattern and, owing to some of the changes that occur in the ligament, these injuries may be less amenable to nonoperative interventions. Further information is used to help develop our differential because there can be several different pathologies associated with medial elbow pain. It is important to note pain location because more posterior pain may be related to an olecranon stress reaction, osteophyte impingement, or triceps tendonitis. Also, if the pain is more proximal or anterior in nature, this may be more reflective of flexor pronator issues. Note at which time point during the throwing motion pain is experienced because the late cocking and early acceleration phase is where the UCL faces the most stress and is commonly noted as painful in the setting of a UCL tear. If a pitcher experiences pain upon deceleration or full extension, this would be less in favor of a UCL injury and more commonly in favor of triceps or other pathology. Lacertus fibrosus syndrome can also cause pain at the anterior medial portion of the elbow and can cause weakness in the median nerve distribution, which can be more obvious with exertion at the elbow. Another common complaint from pitchers is ulnar neuritis, which commonly presents with pain at the medial elbow with radiation and sometimes numbness to the ulnar side of the hand.
Another important aspect of the patient history is how these issues have affected performance, specifically pitch velocity. A common complaint of pitchers with UCL injuries is a loss of velocity or that their arm “feels dead.” It can also be helpful to obtain information from the pitcher and support staff such as coaches and trainers about any recent changes in pitching technique and, more importantly, any rapid increases in pitch velocity because this seems to lead to significantly more medial elbow problems. Elbow injuries are also often preceded by injuries to other parts of the body, most commonly by injuries to the shoulder because mechanics can change and compensation leads to increased stress to the elbow.
Much of the patient history that is obtained can then help guide the physical examination by indicating pertinent areas on which to focus. Obviously, the first step to any examination is inspection, evaluating for any obvious findings such as bruising and swelling. Inspection and evaluation should include a thorough examination of the shoulder, including the scapula. Shoulder examination should focus on signs of overuse and include documentation of glenohumeral internal rotation deficit and scapular dyskinesis because these issues can potentially be corrected during rehabilitation and decrease stress to the elbow. Elbow range of motion (ROM) can be assessed to evaluate any blocks to ROM and because this can be common, and also, if surgery is planned, to establish a postoperative goal for motion because many may lack full terminal extension preoperatively. Palpation of tender areas about the elbow will help guide diagnosis because concomitant flexor pronator tendonitis can occur, which is consistent with pain at the anterior portion of the medial epicondyle (flexor pronator origin) versus directly over the UCL. In differentiating flexor pronator pain from a UCL injury, performing a temple press test ( Fig. 37.1 ) will elicit pain if positive for flexor pronator pathology. Also, resisted wrist flexion and wrist pronation will reproduce pain at the elbow with flexor pronator pathology. Performing a bounce home test ( Fig. 37.2 ) will also elicit pain with posterior impingement. Triceps tendonitis pain is elicited with resisted extension, and palpation of the lacertus fibrosus will produce pain with lacertus fibrosus syndrome.
Several different methods for evaluating UCL injuries to the elbow have been developed. Examination should consist of documenting any laxity to the elbow with valgus stressing and also noting reproduction of symptoms specific to the medial elbow with stressing. Performing a moving valgus stress, as well as the milking maneuver, helps to better identify different flexion angles at which a pitcher experiences pain in the elbow, as this can be performed in the position of the pitching motion and with varying degrees of elbow flexion. This is helpful in diagnosis, as pain may only be elicited during valgus stress at different elbow flexion angles with partial tears.
Other areas to focus on during the physical examination include identifying pathology that may modify the surgical plan. Ulnar nerve symptoms can be common in pitchers with medial elbow pain and should be noted if occurring just during pitching or at rest as well. Examination can be performed noting if Tinel’s sign is positive and also if any subluxation of the nerve is present. If significant ulnar nerve symptoms are present, an electromyography should be obtained as well. A decompression of the nerve or transposition may be indicated with significant symptoms. Limited elbow ROM as well as impingement with pain are important to note because this may require osteophyte excision during surgery, typically with concomitant elbow arthroscopy. Again, osteophytes should only be addressed if symptomatic. Finally, up to 16% of patients will have an absent palmaris tendon ipsilaterally and 9% bilaterally, affecting potential autograft choice for reconstruction. The palmaris tendon can be identified by having patients pinch their thumb to their little finger and then slightly flex the wrist ( Fig. 37.3 ). If the ipsilateral palmaris is absent, the contralateral tendon can be used, if present, or commonly a gracilis or semitendinosus autograft may be chosen; and in some cases, use of allograft tissue has been described. One consideration to discuss with patients concerning a hamstring autograft is that previous studies have shown more hamstring activity in the drive leg compared with the landing leg during pitching. Another study surveyed MLB team physicians and reported that most harvested the landing leg hamstring, if used, because they felt this played a lesser role in the ability to throw a forceful pitch. These are important considerations to keep in mind but should still be left up to surgeon and patient to decide.
The most common imaging modality for definitive diagnosis for a UCL tear is magnetic resonance imaging (MRI). Initial x-rays of the elbow should be obtained to evaluate for intraligamentous calcification, olecranon osteophytes, and loose bodies and to rule out any stress fractures. This is also important in a revision scenario where tunnel placement can be assessed as well. Stress radiographs can also be a valuable tool when assessing for side-to-side differences on x-ray. An example is noted in Fig. 37.4 , in which a player was treated with platelet rich plasma for a proximal tear with subsequent healing, but was unable to return to pitching because of the continued laxity seen in the stress x-rays. Although the ligament healed, it healed elongated, giving the laxity noted in x-ray and the inability to continue pitching ( Fig. 37.4 ).