Ulnar Collateral Ligament Injury

Other Names

• Ulnar collateral ligament injury
• Medial collateral ligament injury
• Valgus Instability
• UCL Disruption
• UCL Attenuation

Pathophysiology

• UCL functions as the primary elbow stabilizer to valgus stress
• Throwing and overhead athletes produce reptitive valgus stress
  • Traction/ tensile forces on their medial structures (UCL, Ulnar Nerve, Common Flexor Tendon)
  • Compression forces on their lateral structures (Radiocapitellar Joint)
  • Compression/impingement forces in their posteromedial compartment
• Forces generated are significant
  • UCL is thought to fail at 34 Newtons
  • 68 N in tennis player serve^[3]
  • Baseball players can generate 64 N
• Chronic traction forces can lead to
  • UCL thickening and hypetrophy
  • Enthesiophyte at the ulna insertion
  • Fatigue of the common flexor tendon
• UCL tear patterns^[4]
  • 87%: torn at the midsubstance
  • 10%: avulsed distally from the ulna
  • 3%: avulsed proximally from the medial epicondyle

Causes

• Chronic overuse
  • Microtrauma from repetitive valgus stress
• Acute
  • Associated with Elbow Dislocation
• Iatrogenic
  • Associated with medial elbow surgeries

• Ulnar Collateral Ligament can be broken down into
  • Anterior Oblique Ligament (AOL)
  • Posterior Oblique Ligament (POL)
  • Transverse Ligament (ligament of Cooper)
• Secondary stabilizers
  • Humeroulnar Joint
  • Common Flexor Tendon represents the dynamic stabilizer to the medial elbow and valgus stress
• Ulnar Nerve Injury
• Valgus Extension Overload Syndrome
• Medial Epicondylitis
  • Partial tears co-occurring in 10-15% of UCL injuries
• Elbow Arthritis
• General
  • Height^[5]
  • Long limb
• Sports
  • Any overhead sports
  • Baseball (especially pitchers)
    • Increased pitching velocity^[6]
    • Increased pitch count^[7][8]
  • Tennis
  • Water polo
  • Volleyball
  • Golf
  • Wrestling
  • Track and field (especially javelin)
  • Football (quarterback)

• Fractures
  • Adult
    • Radial Head Fracture
    • Olecranon Fracture
    • Capitellum Fracture
    • Coronoid Fracture
    • Terrible Triad of Elbow
  • Pediatric
    • Nursemaids Elbow
    • Supracondylar Fracture
    • Lateral Condyle Fracture (Peds)
    • Medial Condyle Fracture (Peds)
    • Olecranon Fracture (Peds)
    • Radial Head Fracture (Peds)
    • Medial Epicondyle Fracture (Peds)
    • Salter Harris Fracture
• Dislocations & Instability
  • Elbow Dislocation
  • Proximal Radioulnar Joint Instability
• Tendinopathies
  • Lateral Epicondylitis
  • Medial Epicondylitis
  • Distal Biceps Tendon Injury
  • Triceps Tendon Injury
• Bursopathies
  • Olecranon Bursitis
• Ligament Injuries
  • Lateral Collateral Ligament Injury (Elbow)
  • Ulnar Collateral Ligament Injury
• Neuropathies
  • Cubital Tunnel Syndrome
  • Radial Tunnel Syndrome
• Arthropathies
  • Elbow Arthritis
• Other
  • Valgus Extension Overload
  • Posteromedial Rotatory Instability
  • Posterolateral Rotatory Instability
  • Osteochondral Defect
• Pediatric Considerations
  • Little League Elbow
  • Panners Disease (Avascular Necrosis of the Capitellum)
  • Nursemaids Elbow (Radial Head Subluxation)

Symptoms

Diagnosis

• History
  • Important to characterize the onset of symptoms: acute, subacute or chronic
  • It is critical to characterize athletes level of participation, hand dominance, sports played, positions etc
  • Inquire about throwing style, ball velocity before and after the onset of elbow pain, throwing accuracy and phase(s) of throwing in which symptoms occur, types of pitches, pitch count, number of innings pitched,
  • Baseball: Pain most commonly during late cocking phase^[4]
  • Tennis: Pain most commonly when the ball hits the racket
• Physical: Physical Exam Elbow
  • In acute injuries you may see swelling, bruising, tenderness
  • Tenderness over the UCL: 81% to 94% sensitivity, 22% specificity for UCL tears^[9]
  • Shoulder range of motion should receive special attention as a Glenohumeral Internal Rotation Deficit is a risk factor for UCL injuries
• Special Tests
  • Elbow Valgus Stress Test: Passively apply a valgus stress test
  • Moving Valgus Stress Test (Elbow): Similar to valgus stress test but with elbow flexion and extension in motion
  • Milking Maneuver: Elbow and shoulder flexed to 90°, physician pulls on thumb
  • UCL laxity is subtle, experienced elbow surgeons only identified 26% to 82% of surgical injuries^[10][11]

Radiographs

• Standard Radiograph Elbow
  • Frequently normal
  • May show avulsion fragment in acute injury
• In chronic injuries, may see:
  • Ossification of the UCL
  • Loose bodies
  • Radiocapitellar and/or ulnohumeral osteophytes
• Stress radiographs
  • Used to detect increased ulnohumeral gapping
  • Sensitivity ranges from 46% – 88%^[10][12]
  • Gravity stress radiograph: AP radiograph with the patient supine, shoulder in maximum external rotation, forearm unsupported
  • Alternative technique: examiner applies a valgus load while the anteroposterior radiograph was obtained
  • There is a device that applies a uniform valgus stress may be used to obtain a stress radiograph
  • Manual and device stress views are not sufficiently sensitive for UCL injuries and not commonly used^[10]
• Comparison to non-dominant elbow may be helpful.
  • Joint space widening on stress radiographs > 0.5 mm in the affected elbow compared with the unaffected elbow indicated a significant partial tear or a complete tear of the UCL^[13]
  • Athletes with widening less < 0.5 mm on stress radiographs compared with the normal elbow had a normal UCL or just a small tear that could be managed conservatively

CT

• Not routinely used
• CT Arthrogram would be study of choice
  • CT Arthrogram is 71% – 86% sensitive, 91% specific for UCL tears^[9]

MRI

• MRI without arthrogram: 57% – 79% sensitive, 100% specific for UCL tears^[9]
• Findings
  • Laxity
  • Irregularity
  • Poor definition
  • Increased signal intensity
• MRI Arthrogram: 97% sensitive for UCL tears^[10]
  • MRI Arthrogram considered gold standard for evaluating UCL injuries
• Findings
  • Fluid extravasation
  • So called “T-sign”
• Can also better evaluate other soft tissue injuries

Ultrasound

• Normal UCL: appears as compact fibrillar echotexture, hyperechoic between the medial epicondyle and proximal ulna
• In throwing athletes, especially pitchers, more likely to appear hypoechoic foci and/or calcifications and have laxity with valgus stress^[15]
• UCL Sprain: May demonstrate thickening, decreased echogenicity of the ligament, and surrounding hypoechoic edema^[16]
• Torn UCL: appear abnormally hypoechogenic, anechoic, and the fibers appear disrupted^[17]
• Pre-injury joint space is widened 1 – 1.5 mm on valgus stress in athletes who eventually developed a UCL tear^[18]

Arthroscopy

• Viewed through the anterolateral portal, most notably the AOL
• Partial (1 to 2 mm) and full-thickness tears (4 to 10 mm) of the AOL can be visualized^[19]
• Timmerman et al: all patients with valgus instability on arthroscopy had AOL tears and all patients without valgus instability had intact, normal AOL on surgical exploration^[9]

Classification

• Strain
• Low-grade partial tear
• High-grade partial tear
• Complete tear

Treatment

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Nonoperative

• First-line treatment in most cases
• Initial treatment
  • Relative rest
  • Physical Therapy: initially non-throwing, progress to throwing
  • NSAIDS
  • Consider elbow splint or brace: Hinged Elbow Brace at 90° or Elbow Hyperextension Brace
  • Consider orthobiologics

Operative

• Indications
  • Complete Rupture
  • Failure of conservative therapy for partial tears
• Technique
  • MCL anterior band ligament reconstruction

Rehabilitation

Nonoperative

• Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow Score (KJOC score)
  • Used to evaluate performance in throwing athlete
  • Has been validated in athletes undergoing UCL reconstruction^[20]
• 2-phase Rehabilitation Protocol (Rettig et al)^[21]
  • 42% of athletes able to return to pre-injury level of play at 24 months
  • Phase 1 (first 2-3 months)
    • No throwing, NSAIDs, icing for 10 minutes 4 times a day
    • Splint/brace at 90° at night and as needed for pain during the day,
    • Active and passive range of motion exercises for flexors and pronators
  • Phase 2 (3 months)
    • Discontinue the splint/brace
    • Begin progressive upper extremity strengthening program of all muscle groups
    • Begin a throwing progression
    • Use an Elbow Hyperextension Brace for throwing and lifting
• Sport-Specific Biomechanical Corrections
  • Baseball pitchers
    • Modify mechanics to decrease the degree of elbow stress
    • Improve: Late trunk rotation, reduced shoulder external rotation, increased elbow flexion, and overhand pitching^[22]
    • Lower pitch count

Post-Operative

• Hariri et al Protocol^[23]
  • Long term goal: maintain shoulder flexibility, strength (periscapular, rotator cuff, core)
  • Immediate postop: splint 70° to 90° of flexion at neutral forearm rotation
  • 10-day follow-up visit: splint is removed and active wrist, elbow, and shoulder range of motion exercises are initiated
    • Hinged elbow brace beginning at 30° to 100°
    • Biomechanical study: full extension and flexion up to 50° with further flexion straining the reconstruction^[24]
    • Range of motion is progressed such that there should be full range of motion by 6 weeks
  • 4 to 6 weeks: an athlete is progressed to strengthening exercises that avoid elbow valgus stress.
  • 8 weeks: elbow brace is removed
  • 14 to 16 weeks: throwing program is initiated
  • Program is progressed such that the average pitcher returns to play at approximately 10 months.
    • Other positions or sports may return sooner

Return To Play

• For sprains, low grade or high grade partial tears
  • May return to play after progressing through physical therapy pain-free
• For complete rupture
  • Needs to be cleared by the surgeon
  • 82% of MLB pitchers return 18.5 months after Tommy John surgery without any major loss in output^[25]

Complications

• Ulnar Nerve Injury^[26]
  • 6.4% transient, 1% persistent
• Injury to Medial Antebrachial Cutaneous Nerve (6%)
• Re-tear (2%)
• Loss of extension > 20° (4%)
• Posterior Elbow Impingement (4.9%)
• Medial Epicondylar Fracture (1.8%)
• Persistent elbow pain (5%)
• Inability to return to sport
• Inability to return to pre-injury level of play

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