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Ulnar Collateral Ligament

Ulnar Collateral Ligament (Medical Collateral Ligament) of the Elbow

  • The ulnar collateral ligament (or UCL) is an important elbow stabilizer
  • Anterior band tightens as elbow is in extension and posterior band tightens with flexion
  • For baseball players (pitchers), the late cocking and acceleration phase of pitching is the trouble spot
    • high level pitchers can hyper externally rotate
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Anterior and Posterior Bands of the UCL

  • The kinetic chain is important
    • Example: Jay “Dizzy” Dean
      • strikeouts were awesome until he broke his toe in the 1937 all star game
      • He had to change his pitching mechanics
      • never enjoyed similar success for the rest of his career
afp20140415p649-f3-300x252 Ulnar Collateral Ligament ER & Clinical Management | HB Ortho Handbook Sports Medicine | HB   baseball_stresses-300x230 Ulnar Collateral Ligament ER & Clinical Management | HB Ortho Handbook Sports Medicine | HB

From: Sakiko Oyama, Baseball pitching kinematics, joint loads, and injury prevention, Journal of Sport and Health Science, Volume 1, Issue 2, September 2012

  • Physical Exam of suspected elbow injury
    • start from bottom and move your way up
    • foot/ankle/knee/hip
      • single leg squat
    • core
    • shoulder (ex. GIRD)
    • Elbow
      • ROM (remember terminal loss of ext is expected)
      • varus/valgus instability at 30
      • milking
        • kind of a stable moving valgus test
      • moving valgus stress test
        • maximum pain is at elbow extension from 120 to 70 of flexion (start in full flexion)
        • mimics arm movement
        • arm in abduction and external rotation – grab thumb and push their elbow with the back of your elbow (standing behind them)
    • Ulnar n.
      • paresthesias
      • wasting of first dorsal interossei
      • subluxation with flexion
    • Shoulder
      • stabilize scapula
        • can place patient supine or place thumb on the coracoid to stabilize it
      • also examine normal arc of motion because in real life scapula is not stabilized
    • X-rays
      • valgus stress x-ray
        • could see some opening medially (although very slight) or you can see some enthesiophytes etc medially in older patients/chronic problems
    • Ultrasound
      • dynamic ultrasound
    • MRI
      • arthrogram probably better, may be able to get away with regular MR in full thickness tear
      • although we focus on the tension side (medial), also look at the compression side
    • Treatment
      • Need to assess tear characteristics as well as demands (sport, level of competition, position, thrower vs. non-thrower, in season vs. out of season)
        • gymnasts are often overlooked, but they usually need to be fixed most of the time, similar to throwers, depending on where they are in their career
        • they walk on their elbows
      • Nonoperative Treatment
        • Biologics
          • lower grade, partial tears may do well with PRP (platelet rich plasma), etc
        • Bracing
        • Very little data
          • Rettig et al
            • 31 athletes
            • UCL insufficiency
            • no difference between complete and partial tears
            • 42% able to return to sports
          • Retrospective Review by Ford et al.
            • 43 injuries
            • all grade 3 treated operatively
            • non operatively treated tears did fairly well
      • Operative Treatment
        • Reconstruction
          • palmaris longus
        • Repair humeral sided avulsion and internal brace
          • best in acute cases with robust ligament
          • be careful not to overtighten in this case
          • maybe better for non-throwers as well
        • Literature
          • Savoie et al. AJSM 2008
            • good results with repair
          • Reconstruction with good results in 80+ % of patients
          • Mean Return-to-Play (RTP) in MLB is 16.8 months (Makhni et al)
        • Complication rate 18.6%, probably lower now
        • Endobutton and docking technique probably best for “load to failure”
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