Ulnar Collateral Ligament of the Elbow

1. Ulnar Collateral Ligament of the Elbow Jacob Kotlicky Program Coordinator Return to Sport – Memorial Hospital West

2. Articulations and Motions • Humeroulnar- Flexion & Extension • Humeroradial – Flexion/Extension, Pronation/Supination • Proximal Radioulnar – Pronation/Supination • Total ROM’s: Flex/Ext = 145˚-155˚ Pro/Sup = 170˚-180˚

3. Ligamentous Support • Ulnar Collateral Ligament - Primary medial stabilizer • Lateral Ulnar Collateral Ligament – Primary lateral stabilizer • Radial Collateral Ligament – supports against varus force, maintains humeroradial articulation • Annular Ligament – permits external/internal rotation of radius & ulna

4. UCL Breakdown • 3 directional bundles • Anterior: Taut throughout full ROM, primary against valgus force • Posterior: Taught in flexion past 60˚ • Transverse: Minimal support to medial elbow

5. Anatomy of the Elbow

6. Injury History/Observations • 20 y/o baseball pitcher • junior classman w/ 0 spring innings played to date on collegiate level • Right hand dominant • No previous history of elbow injury • While throwing a curveball felt a “pop” and instant pain. • Threw two more pitches and felt his arm was “detached” as pain increased • Swelling over the medial aspect of R elbow

7. Palpations/Special Tests • No paresthesia, tinel’s sign, - fractures • Tenderness at UCL and medial epicondyle. • Pain with valgus stress w/ minimal gapping • AROM, PROM, RROM all WNL • Dermatomes/myotomes intact • Suspected UCL sprain. • Athlete prescribed naprosyn and went for immediate MRI

8. MRI Findings • UCL derangement of advanced stage and degree • “High-grade insertional partial tear involving the UCL insertion into the sublime tubercle” • “Thinning and attenuation of the distal inserting fibers” • Prominent edema in flexor pronator musculature • Chondromalacia and synovial thickening about the region.

9. UCL Reconstruction “Tommy John Surgery” • High rate of return to play • Tendon harvested. Typically palmaris longus. Hamstring tendon for this athlete • Tendon prepared – looped through holes drilled in radius and ulna at ligamentous attachment sites • Looped into a figure 8 and then sutured together.

11. Rehabilitation Process • Athlete immediately placed in a functional hinge brace • Extension initially limited to 60˚ • Total amount of time braced will be 5-6 weeks • In-clinic 2 x week supplemented by HEP on daily basis • 4 way SLR, heel drags and HS stretches • Shoulder isometrics

12. Rehabilitation Cont. • Began passive stretching of biceps on 11/17/08 – Athlete is hesitant with tightness and pain due to held flexion for nearly two weeks.

13. Return to Play Criteria • FULL ROM • Strength must be equal to that of other arm • No c/o pain in elbow w/ activity • Completion of shoulder program • Medical clearance from Dr. K.

14. References Koh, JL, Schafer, MF, Keuter, G, & Hsu, JE. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy. 22 (11): 1187-1191  Safran, MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment. Clin Sports Med. 23 (4): 643-663 Chen FS, Rokito AS, & Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 9 (2): 99-113 Cain EL, & Dugas JR. History and examination of the thrower’s elbow. Clin Sports Med. 23 (3) 553-566 Limpisvasti O, ElAttrache NS, Jobe FW. Understanding shoulder and elbow injuries in baseball. J Am Acad Orthop Surg. 15 (3): 139-147 Hyman, J, Breazeale, NM, & Altchek, DW. Arthroscopic surgery for athletic elbow and wrist surgeries. Clin Sports Med. 20 (1): 5-21 Altcheck D, Hyman JL, Williams RJ. Ulnar collateral ligament reconstruction in throwers using the “docking” technique: two-year results. Sun Valley, ID, American Orthopaedic Association, 1999 Starkey C, Ryan J. Evaluation of Orthopedic and Athletic Injuries. 2nd ed. Philadelphia, Pa: FA Davis Company; 2002

15. QUESTIONS???