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Ulnar Collateral Ligament: Anatomy & Mechanism of Injury Review

Ulnar Collateral Ligament: Anatomy & Mechanism of Injury Review Matthew Kiessling, MS ATC PES CES Summa Health System - Sports Health. 2. FINANCIAL DISCLOSURES

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Ulnar Collateral Ligament: Anatomy & Mechanism of Injury Review

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  1. Ulnar Collateral Ligament: Anatomy & Mechanism of Injury Review Matthew Kiessling, MS ATC PES CES Summa Health System - Sports Health 2

  2. FINANCIAL DISCLOSURES As a planner and speaker, I have NO significant financial, commercial or proprietary interest/arrangement or affiliation with one or more corporate organizations. Furthermore, there is NO special interest with any device, equipment, instrument described that could be perceived as real or apparent conflict of interest in todays presentation and context of remarks made today. 3

  3. OBJECTIVES • Review of Functional and Structural Anatomy of Elbow • Explained Incidences and Rarity of Elbow Injuries, Specifically UCL • Analysis of Mechanism of Injury Pertaining to the UCL • Described Evaluation, Signs and Symptoms in the AT Room • Guidelines for Referral to Physicians • Lead into Sports Medicine, Surgical and Rehabilitation Approaches 4

  4. HISTORICAL PERSPECTIVE • 1940's, First Publishings, “Generic Dead Arm”1,2 • 60's; MLB reached 50% with Elbow Problems 3 • Nearly 67% of all pitchers had Degenerative Elbow Diseases 2 • Focused term change to “Medial Elbow-Stress Syndrome” 1,3 • First UCL Reconstruction, Dr. Frank Jobe, 1974 on Tommy John 1,4,6-8 • Second Most Common Joint to be Injuried15 • 50 to 70% of adolescents have shoulder and elbow pain 19 • 17% to 45% of adolescents record these problems 19 • 5% of pitchers who has sustained serious elbow and shoulder injury will require surgery 46 5

  5. PROMINENT FIGURES Dr. Frank Jobe Dr. James Andrews Dr. Glenn Fleisig 6

  6. THE ULNAR COLLATERAL LIGAMENT • Three Bundles (Anterior, Transverse & Posterior Bands) 18,19 7

  7. FUNCTIONAL AND STRUCTURAL ANATOMY 8

  8. FUNCTIONAL AND STRUCTURAL ANATOMY 9

  9. FUNCTIONAL AND STRUCTURAL ANATOMY 10

  10. MECHANISM OF INJURY • Adaptive Changes from Prolonged and Repetitive Throwing 5 • Microtraumatic Stress • 2300 degrees per second • 300 N, Medial Shear Force • 900 N, Compressive Force25,48,49,50,56 • Shoulder Internal & Elbow Valgus Torque to Counter and Decelerate 16 • Mean Adult, 64 N per pitch • Mean torque allowed by UCL • 34 N/54% varus counter torque 11

  11. RESEARCH AND ANALYSIS • Strongest Correlation to Injury is Amount of Pitching46,47 • Studies done by Olsen, Fleisig, University of North Carolina • Concluded: • Months per Year Pitching (< than 8 months; fivefolds) • Innings per Game (< than 100 innings in 1 yr; 3.5x) • Pitches per Game (< than 80/75 for youth; quadruple the risk) • Pitching for Multiple Teams at Same Time • Lack of Rest Periods • Pitching with Fatique (increase risk to 36x) 10,16,64,65 But Why? Baseball players now have more opportunity to play extensive schedules 65 12

  12. RESEARCH AND ANALYSIS • Specific technique flaws associated with increased valgus torque include hand under the ball during the stride phase. 46 • Late arm rotation,72 Excessive shoulder external rotation,73,70 Excessive elbow flexion,73 Improper shoulder abduction and trunk tilt.74 13

  13. RESEARCH AND ANALYSIS • The premise is that young athletes in warm climates have opportunities to play organized baseball for more months each year and increased exposure to throwing arm injury risk, whereas northern climates may restrict the participation in throwing and have lower injury risk • Mean for Cold: 6 months; Mean for Warm: 9 months 14

  14. RESEARCH AND ANALYSIS • For generations, experts have pointed to curveballs as a source of pain and injury to the elbow. • In theory, the pitcher must put his arm in a position that increases strain on the elbow to cause the ball to spin. • Because youth pitchers are skeletally immature, the growth plates at the origin and insertion of the UCL cannot safely withstand such increased strain 16,75 • Studies done by Dunn, Nissen, Fleisig, Olsen and University of North Carolina in biomechanical, retrospective, and prospective methods • Concluded: • Studies found significantly > or no difference in elbow valgus torque with fastball, than curveball mechanics • Found no evidence that throwing breaking pitches at an early age was an injury risk factor 11,16,23,47,66,67,69 15

  15. THE EVALUATION • Detailed History • Physical Examination • Soft Tissue Palpation • AROM & PROM • Manual Muscle Testing • Handshaking/Various Grip Test • Compression Test • Special Test • Valgus Stress Test 78,79 • Milking Test 80 • Tinels Sign • Apprehension Stress Test • Hyperextension Stress Test • Compare Bilaterally • Observe Differences in Joint above and below • Supportive Imaging Modalities 16

  16. GUIDELINES FOR REFERRAL • Gross Deformities • Significant Swelling • Considerable Pain • Significant Loss of Motion • Audible “Clicks” “Pops” during Evaluation • Loss of Sensation below the Elbow • Abnormal Sensations that Don't Subside • Joint Instability • Suspected Facture or Dislocation 17

  17. Thank You!! 18

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