Elbow Ulnar Collateral Ligament Injury Joshua S

Elbow Ulnar Collateral Ligament Injury Joshua S. Dines • David W. Altchek Editors

Elbow Ulnar Collateral Ligament Injury A Guide to Diagnosis and Treatment Editors Joshua S. Dines David W. Altchek Sports Medicine and Shoulder Service Sports Medicine and Shoulder Service Hospital for Special Surgery Hospital for Special Surgery New York New York New York New York USA USA

Videos to this book can be accessed at http://link.springer.com/book/10.1007/978-1-4899-7540-9.

ISBN 978-1-4899-7539-3 ISBN 978-1-4899-7540-9 (eBook) DOI 10.1007/978-1-4899-7540-9

Library of Congress Control Number: 2014959417

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Printed on acid-free paper

Springer US is part of Springer Science+Business Media (www.springer.com) Before Dr. Frank Jobe (1925–2014) created the “Tommy John Procedure” for Ulnar Collateral Ligament reconstruction, UCL injury was career ending. His ingenuity and surgical skill transformed this injury into a procedure commonly performed with a success rate approaching 90 %. Lewis Yocum MD (1947–2013) trained with Dr. Jobe at the Kerlan Jobe Clinic in Los Angeles. He, too, became a world- renowned sports surgeon serving as the team doctor for the LA Angels of Anaheim for 36 years. The following monograph is dedicated to both Frank Jobe MD and Lewis Yocum MD. Both were outstanding surgeons and even better people. Their dedication to treating baseball players saved the careers of thousands of players at all levels worldwide.

v Foreword

I can think of few textbooks more timely in the field of sports medicine than the following on elbow ulnar collateral ligament injuries. Not only has the 2014 baseball season seen an alarming increase in the number of these injuries but it was also prior to the 2014 season during which two of the forefathers of baseball medicine passed away: Dr. Frank Jobe and Dr. Lewis Yocum. I can think of no better tribute to these men than this book which features chapters written by many of their former students, fellows, and colleagues. David and Josh, the editors, have assembled all of the current thought leaders in the field to address the topic of ulnar collateral ligament (UCL) injury in a more thorough way than has been done before. Not only does the monograph cover the basics like exam and imaging of the elbow in a thorough and read- able way but it also tackles complicated topics such as revision UCL reconstruction and UCL reconstruction in high school athletes. Furthermore, there is an outstanding section on nonoperative treatment as well as postoperative rehabilitation, which will surely be of interest to surgeons and non-surgeons alike. As UCL injuries continue to be more common, I am confident that this book will find its way on to the shelves of all doctors, therapists and trainers who treat these injuries.

Kerlan Jobe Orthopedic Clinic Neal S. Elattrache, MD Los Angeles CA

vii Preface

Since the initial description of elbow ulnar collateral ligament reconstruction by Dr. Frank Jobe, the use of the procedure to save the careers of baseball players (and other athletes) at all levels of play has increased exponentially. Over the last decade, our understanding of the biomechanics of throwing has improved, as has our ability to diagnose injuries in these athletes. Given these advances, we believed that a monograph dedicated to the diagnosis and treatment of injuries of the UCL would be of interest to the doctors, therapists and trainers who work with athletes that suffer these injuries. We have assembled a world-class group of authors to review the biomechanics and pathophysiology of throwing injuries. Keys to performing a physical exam in this unique group of patients are highlighted in the text as are pearls to interpreting imaging studies. Since Dr. Jobe’s initial description of the technique that he used to recon- struct pitcher Tommy John’s ligament, several modifications have been described. All currently-used techniques are illustrated here with both pic- tures and video. Outcomes are discussed in detail as they pertain to individual reconstruction constructs as well as to particular sports. As anyone who treats these injuries knows, proper rehabilitation is critical to getting athletes back to their previous level of play. In this book, experts outline appropriate rehabilitation protocols and timelines. We hope that this monograph helps readers gain a better understanding of UCL injuries with the goal of not only improving outcomes after UCL reconstruction but also preventing these injuries.

New York, NY Joshua S. Dines and David W. Altchek

ix Contents

1 Clinically Relevant Elbow Anatomy and Surgical Approaches �� 1 Xinning Li and LTC Josef K. Eichinger

2 Ulnar Collateral Ligament: Throwing Biomechanics �� 11 Kenneth Durham Weeks and David M. Dines

3 Valgus Extension Overload �� 17 David C. Gerhardt and E. Lyle Cain

4 Ulnohumeral Chondral and Ligamentous Overload �� 27 Sheref E. Hassan and Daryl C. Osbahr

5 Epidemiology of Elbow Ulnar Collateral Ligament Injuries �� 35 Lauren M. Fabian and Stan A. Conte

6 History and Physical Exam on the Thrower’s Elbow �� 43 William Piwnica-Worms, Brian Grawe and Joshua S. Dines

7 Radiographic Imaging of the Elbow �� 53 Susie Muir and John V. Crues

8 MR Imaging in Patients with Ulnar Collateral Ligament Injury �� 67 Brett Lurie, Jan Fritz and Hollis G. Potter

9 Ultrasound Imaging of Ulnar Collateral Ligament Injury �� 79 Michael C. Ciccotti M.D., Levon N. Nazarian M.D. and Michael G. Ciccotti M.D.

10 The Conservative Treatment of Ulnar Collateral Ligament Injuries �� 93 Jaicharan J. Iyengar and Christopher S. Ahmad

11 Injections Including Platelet-Rich Plasma �� 99 Michael E. Angeline, John M. Zajac, Albert O. Gee, Joshua S. Dines and David W. Altchek

xi xii Contents

12 Ulnar Collateral Ligament Reconstruction: Graft Selection and Harvest Technique �� 107 James E. Voos

13 Primary Repair of Ulnar Collateral Ligament Injuries of the Elbow �� 115 Felix H. Savoie, Michael J. O’Brien and Larry D. Field

14 The Role of Arthroscopy in Athletes with Ulnar Collateral Ligament Injuries �� 125 Curtis Bush and John E. Conway

15 Biomechanics of Reconstruction Constructs �� 135 Miguel A. Ramirez and Anand M. Murthi

16 Figure of 8 Technique and Outcomes �� 141 Tony Wanich, Jared M. Newman and Lewis A. Yocum

17 Ulnar Collateral Ligament Reconstruction: Docking Technique �� 149 Joshua S. Dines, Alexandra D. Berger and David W. Altchek

18 American Sports Medicine Institute Techniques and Outcomes �� 155 Anthony James Scillia and Jeffrey R. Dugas

19 Ulnar Collateral Ligament Reconstruction: Alternative Surgical Techniques �� 167 Benjamin C. Service, Neal S. ElAttrache and Daryl C. Osbahr

20 Combined Flexor-Pronator Mass and Ulnar Collateral Ligament Injuries �� 175 Alexander Christ, Joshua S. Dines, Christopher Chin and David W. Altchek

21 Ulnar Nerve Issues in Throwing Athletes �� 179 Albert O. Gee, Michael E. Angeline, Joshua S. Dines and David W. Altchek

22 Revision Ulnar Collateral Ligament Reconstruction �� 189 Andrew J. Rosenbaum, Michael A. Flaherty, Christopher Chin, Neal S. Elattrache and Joshua S. Dines

23 Ulnar Collateral Ligament Injuries in High-School-Aged Athletes �� 195 Lauren M. Fabian and Orr Limpisvasti Contents xiii

24 Ulnar Collateral Ligament Injury in Female Athletes �� 205 Elizabeth C. Gardner and Asheesh Bedi

25 Complications of Ulnar Collateral Ligament Repair �� 213 Travis G. Maak and Robert Z. Tashjian

26 Sports Specific Outcomes for Ulnar Collateral Ligament Reconstruction �� 219 Thomas O’Hagan, Charlton Stucken and Christopher C. Dodson

27 Rehabilitation of the Overhead Athlete’s Elbow �� 227 Kevin E. Wilk, Todd S. Ellenbecker and Leonard C. Macrina

28 Sport-Specific Rehabilitation After Ulnar Collateral Ligament Surgery �� 261 Todd S. Ellenbecker and Kevin E. Wilk

Index �� 279 Contributors

Christopher S. Ahmad, MD Center for Shoulder, Elbow & Sports Medicine, Columbia University Medical Center, New York, NY, USA David W. Altchek, MD Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA Michael E. Angeline, MD Mercy Health System, Janesville, WI, USA Orthopaedic Surgery—Sports Medicine Service, Mercy Health System, Janesville, WI, USA Asheesh Bedi, MD Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA Alexandra D. Berger, BA University of Miami Jupiter, FL, USA Curtis Bush, MD TH Harris Methodist Fort Worth Hospital, Ft Worth, TX, USA E. Lyle Cain, MD Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL, USA Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, NY, USA Christopher Chin, BS Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA Alexander Christ, MD Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, NY, USA Michael C. Ciccotti, MD Department of Orthopaedic Surgery, Thomas Jefferson Uni- versity Hospital, Philadelphia, PA, USA Michael G. Ciccotti, MD Everett J� and Marian Gordon Professor of Orthopaedic Sur- gery; Chief, Division of Sports Medicine; Director, Sports Medicine Fellowship and Research; Head Team Physician, Philadelphia Phillies Baseball and St� Joseph’s Univer- sity, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA Stan A. Conte, ATC, PhD Senior Medical Director, LA Dodgers Baseball Club San Carlos, CA, USA John E. Conway, MD TH Harris Methodist Fort Worth Hospital, Fort Worth, TX, USA John V. Crues, MD Musculoskeletal Radiology, Radnet, Inc�, Los Angeles, CA, USA

xv xvi Contributors

Department of Radiology, University of California, San Diego (UCSD), San Diego, CA, USA David M. Dines, MD Orthopedic Surgery, Sports & Shoulder Service, Hospital for Special Surgery, Weill Cornell, Medical College, Uniondale, NY, USA Joshua S. Dines, MD Orthopedic Surgery, Sports & Shoulder Service, Hos- pital for Special Surgery, Weill Cornell, Medical College, Uniondale, NY, USA Christopher C. Dodson, MD Rothman Institute, Philadelphia, PA, USA Jeffrey R. Dugas, MD Andrews Sports Medicine and Orthopedic Center Birmingham, AL, USA LTC Josef K. Eichinger, MD Orthopaedics Department, Madigan Army Medical Center, Tacoma, WA, USA Neal S. Elattrache, MD Kerlan Jobe Orthopedic Clinic, Los Angeles, CA, USA Todd S. Ellenbecker, MS, PT, SCS, OCS, CSCS Physiotherapy Associates Scottsdale Sports Clinic, Scottsdale, USA Clinical Research, Physiotherapy Associates, Scottsdale, USA ATP World Tour, Physiotherapy Associates Schottsdale Sports Clinic, Scott- sdale, AZ, USA Lauren M. Fabian, MD Kerlan Jobe Orthopaedic Clinic, Los Angeles, CA, USA Larry D. Field, MD Mississippi Sports Medicine and Orthopaedic Center, Jackson, MS, USA Michael A. Flaherty, MD Sports Medicine Orthopaedic Surgery, Capital Region Orthopaedics Group, Albany, NY, USA Jan Fritz, MD Radiology & Imaging, MRI Division, Hospital for Special Surgery, New York, NY, USA Elizabeth C. Gardner, MD Orthopaedic Surgery, Yale University, New Haven, CT, USA Albert O. Gee, MD Department of Orthopaedics and Sports Medicine, Uni- versity of Washington Medical Center, Seattle, WA, USA Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA David C. Gerhardt, MD Andrews Sports Medicine and Orthopaedic Cen- ter, Birmingham, AL, USA Brian Grawe, MD Department of Orthopaedics and Sports Medicine, Uni- versity of Cincinnati Academic Health Center, Cincinnati, OH, USA Contributors xvii

Sheref E. Hassan, MD Orthopaedics and Sports Medicine, MedStar Union Memorial Hospital, Baltimore, MD, USA Jaicharan J. Iyengar, MD Center for Shoulder, Elbow & Sports Medicine, Columbia University Medical Center, New York, NY, USA Xinning Li, MD Sports Medicine and Shoulder & Elbow Surgery, Department of Ortho- paedics, Boston University School of Medicine, Boston, MA, USA Orr Limpisvasti, MD Orthopaedic Surgeon, Kerlan Jobe Orthopaedic Clinic, Los Ange- les, CA, USA Brett Lurie, MD Radiology & Imaging, MRI Division, Hospital for Special Surgery, New York, NY, USA Travis G. Maak, MD Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA Leonard C. Macrina, MSPT, SCS, CSCS Physical Therapy, Champion Physical Ther- apy and Performance, Waltham, MA, USA Susie Muir, MD Radnet Inc�, Los Angeles, CA, USA Anand M. Murthi, MD Department of Orthopaedics, MedStar Union Memorial Hospi- tal, Baltimore, MD, USA Levon N. Nazarian, MD Professor of Radiology; Vice Chair of Education, Department of Radiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA Jared M. Newman, MD Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA Michael J. O’Brien, MD Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA Thomas O’Hagan, MD Rothman Institute, Philadelphia, PA, USA Daryl C. Osbahr, MD Chief of Sports Medicine, Orlando Health Orthopedic Institute, Orlando, FL, USA William Piwnica-Worms, BA Orthopaedics Department, Hospital for Special Surgery, New York, NY, USA Hollis G. Potter, MD Radiology & Imaging, MRI Division, Hospital for Special Surgery, New York, NY, USA Miguel A. Ramirez, MD Department of Orthopaedics, MedStar Union Memorial Hos- pital, Baltimore, MD, USA Andrew J. Rosenbaum, MD Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA Felix H. Savoie, MD Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA, USA Anthony James Scillia, MD American Sports Medicine Institute, Orthopaedic Surgery, Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL, USA xviii Contributors

Benjamin C. Service, MD Orlando Health Orthopedic Institute, Orlando, FL, USA Charlton Stucken, MD Rothman Institute, Philadelphia, PA, USA Robert Z. Tashjian, MD Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA James E. Voos, MD Division Chief, Orthopaedic Sports Medicine, Univer- sity Hospitals Cleveland, Cleveland, OH, USA Tony Wanich, MD Montefiore Medical Center, Brone, NJ, USA Kenneth Durham Weeks, MD Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA Kevin E. Wilk, PT, DPT Champion Sports Medicine, Physiotherapy Asso- ciates, Birmingham, AL, USA Lewis A. Yocum, MD Kerlan Jobe Orthopaedic Clinic, Los Angeles, CA, USA John M. Zajac, PT New York Mets Baseball Club, Flushing, NY, USA