What are the treatment options for UCL tears of the elbow in athletes?
Christopher Doumas, MD
Clinical Assistant Professor Orthopaedic Surgery Rutgers-RWJMS
Chief of Hand Surgery JSUMC Disclosures
• President and Founder of LibraryOfMedicine.com
www.UOANJ.com Clinical Question
• In the athle c popula on, what are the treatment op ons for pa ents with an ulnar collateral ligament tear of the elbow, who wish to return to normal physical ac vity?
www.UOANJ.com Overhead Throwing
• Results in significant valgus stress to the elbow • Stress concentrated on medial structures • Majority of injuries secondary to repe ve overload rather than acute trauma • Baseball players most commonly affected • Medial elbow symptoms account for 97% of elbow complaints in pitchers Elbow stability
• Primary stability at < 20° or >120° of flexion is secondary to bony anatomy • So ssue restraints provide primary sta c and dynamic stability from 20-120° = arc of mo on of overhead throwing Ulnar Collateral Ligament
• Anterior Bundle is primary restraint to valgus force from 30-120° of flexion • Anterior Bundle made up of anterior (up to 90°) and posterior bands (60°- full flexion) • During accelera on phase of throwing subjected to near failure tensile stresses • Posterior Bundle vulnerable to valgus stress only if anterior bundle fails • Oblique bundle: serves to expand sigmoid notch Stages of Overhead Throwing Obviously Confused… Biomechanics of Throwing
• Generates large valgus and extension forces • Valgus force as high as 64 Nm at late cocking and early accelera on, Compressive force of 500 N lateral radiocapitellar ar cula on as extend • Net effect: Tensile stress along medial structures, shear stress in posterior compartment, compression stress laterally • Together → Valgus Extension Overload Syndrome Spectrum of Injury
• UCL a enua on/tears • Olecranon p osteophytes • Loose bodies • Flexor-pronator mass tendoni s • Ulnar neuri s • Medial epicondyle apophysi s in skeletally immature Evaluation of Elbow Complaints
• History: Changes in training regimen Changes in accuracy, velocity, stamina, strength Time of onset Phase of throwing Neurologic or vascular complaints
Evaluation of Elbow Complaints
• Physical exam:
Inspec on: effusion, carrying angle (nl 11° valgus ♂, 13° ♀, adap ve changes in throwers can increase, assess deformity from prior trauma)
ROM: ac ve, passive (sagital 0-140°±10°, 80-90° prona on and supina on, assess for contracture, compensa on w/ shoulder) Flexion contracture present in 50% of pitchers, End points: so in flexion, firm bone on bone in extension
Palpa on: bony landmarks: medial epicondyle, radial head, p of olecranon; So ssues: biceps, triceps, flexor-pronator mass, UCL; neurovascular structures
Strength Tes ng Stability Evaluation of Elbow Complaints
• Plain Radiographs AP, lateral, axial, 2 oblique views Oblique axial view at 110° flexion → posteromedial olecranon osteophytes Stress AP radiographs at 25° flexion w/ comparison to opposite elbow assessing for osteophytes, UCL calcifica on, OCD of capitellum, loose bodies
• CT Scan: olecranon stress fx • Bone Scan: olecranon stress fx • MRI vs CT arthrogram: UCL evalua on • Ultrasound – Can be reliably used to assess integrity, early pathologic change and increased laxity to valgus stress. – Early change is increased thickness of the UCL.
Cicco et al.
Evaluation of Valgus Instability: History • Acute Injury: ▪ sudden onset of pain a er throwing ± pop ▪ unable to con nue throwing • Chronic Injury: ▪ gradual onset of localized medial elbow pain during late-cocking or accelera on ▪ pain a er episode of heavy throwing w/ subsequent inability to throw at more than 50-70% of nl level ▪ ulnar nerve symptoms 2° to irrita on from local inflamma on Exam of Anterior Band of Anterior Bundle of UCL • Pt seated, wrist secured between examiner’s forearm and trunk • Flex elbow to 20-30° to unlock olecranon from fossa • Apply valgus stress, and palpate UCL along its course • Compare medial joint-space opening to contralateral side • Loss of firm endpoint w/ increased medial joint- space opening → a enuated or incompetent UCL
Exam of Posterior Band of Anterior Bundle of UCL: Milking Maneuver • Pull on pt’s thumb w/ pt’s forearm supinated, shoulder extended, and elbow flexed beyond 90° • Results in valgus stress on flexed elbow • Subjec ve feeling of apprehension and instability + localized medial elbow pain indicates UCL injury Moving Valgus Stress Test
• Pain from 70 -120
• 100% Sensi ve • 75% Specific
O’Driscoll et al. Am J Sports Med. 2005 Feb; 33(2):231-9 Other Exam findings
• Point tenderness and swelling may vary • Decreased Range of mo on w/ loss of terminal extension secondary to flexion contracture may be present w/ chronic valgus instability Radiographic Findings
• Calcifica on and occasional ossifica on of the UCL • Stress radiographs compared w/ contralateral elbow, AP view at 25 degrees of flexion w/ gravity valgus stress applied • > 3mm of medial joint opening sugges ve
Langer et al. Br J Sports Med. 2006;40:499-506.
Usefulness of MRI vs CT arthrogram
• Nonenhanced MRI vs CT arthrogram in 25 pa ents w/ surgically confirmed UCL injury MRI CT arthrogram Sensi vity 57% 86% Specificity 100% 91% Both 100% sensi vity for complete tears
• Saline-enhanced arthrogram MRI Sensi vity 92% (95% for complete tear, 86% for par al) Specificity 100%
Treatment Options
• Conserva ve – Therapy – PRP
• Surgical – Acute Repair – Chronic Reconstruc on
www.UOANJ.com PubMed Search
• Elbow Ulnar Collateral Ligament Injury • 301 Ar cles
• No good Level I or II studies
www.UOANJ.com Conservative Options
• Non opera ve treatment is indicated in non- throwers, and has acceptable results in this lower- demand popula on
• Rehab 2-3 month of non-throwing, splin ng un l pain improved and ROM and PT of the shoulder
• Injec on of the UCL with cor costeroid should be avoided
Langer et al. Br J Sports Med. 2006;40:499-506.
www.UOANJ.com Therapy
• The flexor-pronator mass dynamically stabilizes the elbow against valgus torque. The flexor carpi ulnaris is the primary stabilizer, and the flexor digitorum superficialis is a secondary stabilizer. The pronator teres provides the least dynamic stability.
Park and Ahmad. J Bone Joint Surg Am, 2004 Oct; 86 (10): 2268 -2274 .
www.UOANJ.com Non-Op Literature
• 18 NFL players with UCL injuries – All returned to play – Obviously mostly Non-throwers Kenter et al. J Shoulder Elbow Surg. 2000 Jan-Feb;9(1):1-5.
• Re g et al found 42% RTP avg of 24.5 weeks a er diagnosis (Mean age 18) Re g et al. Am J Sports Med. 2001 Jan-Feb;29(1):15-7
www.UOANJ.com PRP
• Case series of 34 athletes (Level 4) – Ultrasound diagnosis and followup measurements – Less widening of medial joint space on follow up – 88% returned to play (avg me 12 weeks) – 1 went on to surgery
Podesta et al. Am J Sports Med. 2013 Jul;41(7):1689-94.
www.UOANJ.com UCL Direct Ligament Repair
• ONLY in acute trauma c rupture without disloca on. • 9/11 collegiate athletes returned to play within 6 months • Works even in throwers Richard et al. J Bone Joint Surg Am. 2009 Oct 1;91
www.UOANJ.com Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament
• 60 adolescent pa ents with direct repair • Good to excellent results in 93% • Less likely to have chronic damage. • 58 of 60 able to return to original or higher level of play within 6 months.
Savoie et al. Am J Sports Med 2008.
www.UOANJ.com Repair vs Reconstruct
Conway et al. J Bone Joint Surg Am. 1992 Jan;74(1):67-83. • Return to play prior level – 50% of Repair Group – 68% of Reconstruc on Group • Major League Players Returning – 2/7 Repair Group – 12/16 Reconstruc on Group
www.UOANJ.com Repair vs Reconstruct
• Andrews et al – Repair – 0/2 RTP – Recon – 12/14 (86%) RTP Am J Sports Med. 1995 Jul-Aug;23(4):407-13.
www.UOANJ.com UCL Ligament Reconstruction
• 1986 Jobe et al. • Figure of eight gra • All throwers • 10/16 returned to play
www.UOANJ.com Docking Technique
• 1996 Described by Altchek
• Rohrbough et al reported 92% RTP for at least one year
www.UOANJ.com Post-operative Rehabiltation
• Brief Immobiliza on 7-10 days, followed by AAROM and AROM • Hinged brace- 5 weeks a er splint, 20-140 degrees • Progressive resis ve strengthening exercises of wrist and forearm 4-6 wks • At 6 weeks begin elbow strengthening exercises • Avoid valgus stress un l 4 months • Throwing program beginning at 4 months • Condi oning of shoulder and elbow progress w/ return to pre-injury ac vity by 12-18 months
University of Pennsylvania Department of Orthopaedic Surgery Clinical Conclusions
• Injury to the medial collateral ligament of the elbow is rela vely common in athle cs. • Appropriate clinical exam and diagnos c studies should be u lized. • Conserva ve treatment and rehabilita on should be considered for injuries that have no significant laxity on exam in a non-thrower.
www.UOANJ.com Clinical Conclusions
• Surgical treatment has good outcomes for pa ents with valgus laxity.
• Decreased dissec on of the flexor pronator mass leads to be er outcomes
• Decreased handling of the ulnar nerve leads to be er outcomes
www.UOANJ.com Bottom Line
• Injury to the UCL can have a significant impact normal func on of the elbow. This is even more important in the throwing athlete.
• It is important to iden fy subtle instability and implement an appropriate course for treatment. – Par al tears, ultrasound capabili es
www.UOANJ.com Thank you!
Interference Technique
www.UOANJ.com References
• Am J Sports Med. 2013 Jul;41(7):1689-94. doi: 10.1177/0363546513487979. Epub 2013 May 10. Treatment of par al ulnar collateral ligament tears in the elbow with platelet-rich plasma. Podesta L1, Crow SA, Volkmer D, Bert T, Yocum LA.
www.UOANJ.com • Am J Sports Med. 2005 Feb;33(2):231-9. The "moving valgus stress test" for medial collateral ligament tears of the elbow. O'Driscoll SW1, Lawton RL, Smith AM.
www.UOANJ.com • Dynamic Contribu ons of the Flexor-Pronator Mass to Elbow Valgus Stability. Maxwell C. Park, MD; Christopher S. Ahmad, MD. J Bone Joint Surg Am, 2004 Oct; 86 (10): 2268 -2274 .
www.UOANJ.com • Curr Rev Musculoskelet Med. 2008 Dec; 1(3-4): 197–204. • Published online 2008 Jun 6. doi: 10.1007/ s12178-008-9026-3 • PMCID: PMC2682408 • Elbow medial collateral ligament injuries • Ra’Kerry K. Rahman, William N. Levine, and Christopher S. Ahmadcorresponding author
www.UOANJ.com • Am J Sports Med. 2015 Sep 24. pii: 0363546515605042. [Epub ahead of print]. Early Anatomic Changes of the Ulnar Collateral Ligament Iden fied by Stress Ultrasound of the Elbow in Young Professional Baseball Pitchers. Atanda A Jr1, Buckley PS2, Hammoud S2, Cohen SB2, Nazarian LN3, Cicco MG2.
www.UOANJ.com • Am J Sports Med 2008. Jun;36(6):1066-72. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. SavoieFH, Trenhaile SW, Roberts J, Field LD, Ramsey JR.
www.UOANJ.com • J Shoulder Elbow Surg. 2000 Jan-Feb;9(1):1-5. Acute elbow injuries in the Na onal Football League. Kenter K, Behr CT, Warren RF, O'Brien SJ, Barnes R.
www.UOANJ.com • Am J Sports Med. 2001 Jan-Feb;29(1):15-7. Nonopera ve treatment of ulnar collateral ligament injuries in throwing athletes. Re g AC, Sherrill C, Snead DS, Mendler JC, Mieling P.
www.UOANJ.com • Radiology. 1995 Oct;197(1):297-9. Ulnar collateral ligament injury in the throwing athlete: evalua on with saline-enhanced MR arthrography. Schwartz ML1, al-Zahrani S, Morwessel RM, Andrews JR.
www.UOANJ.com • Am J Sports Med. 1994 Jan-Feb;22(1):26-31; discussion 32. Preopera ve evalua on of the ulnar collateral ligament by magne c resonance imaging and computed tomography arthrography. Evalua on in 25 baseball players with surgical confirma on. Timmerman LA1, Schwartz ML, Andrews JR.
www.UOANJ.com • J Bone Joint Surg Am. 2009 Oct 1;91 Suppl 2:191-9. doi: 10.2106/JBJS.I.00426. Trauma c valgus instability of the elbow: pathoanatomy and results of direct repair. Surgical technique. Richard MJ, Aldridge JM 3rd, Wiesler ER, Ruch DS.
www.UOANJ.com • Am J Sports Med. 2008 Jun;36(6):1066-72. doi: 10.1177/0363546508315201. Epub 2008 Apr 28. Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament. Savoie FH 3rd1, Trenhaile SW, Roberts J, Field LD, Ramsey JR.
www.UOANJ.com • J Bone Joint Surg Am. 1992 Jan;74(1):67-83. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruc on of the ulnar collateral ligament. Conway JE, Jobe FW, Glousman RE, Pink M.
www.UOANJ.com • Am J Sports Med. 1995 Jul-Aug;23(4):407-13. Outcome of elbow surgery in professional baseball players. Andrews JR, Timmerman LA.
www.UOANJ.com • Br J Sports Med. 2006;40:499-506. Evolu on of the treatment op ons of ulnar collateral ligament injuries of the elbow. Langer P, Fadale P, Hulstyn M.
www.UOANJ.com • Am J Sports Med. 2002 Jul-Aug;30(4):541-8. Medial collateral ligament reconstruc on of the elbow using the docking technique. Rohrbough JT1, Altchek DW, Hyman J, Williams RJ 3rd, Bo s JD.
www.UOANJ.com • J Ultrasound Med. 2015 Mar;34(3):371-6. doi: 10.7863/ultra.34.3.371. Reliability and precision of stress sonography of the ulnar collateral ligament. Bica D1, Armen J2, Kulas AS2, Youngs K2, Womack Z2.
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