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UCL Tear

From WikiSM

Other Names

  • Ulnar collateral ligament injury
  • Medial collateral ligament injury
  • Valgus Instability
  • UCL Disruption
  • UCL Attenuation
  • Ulnar collateral ligament tear
  • UCL injury
  • Ulnar collateral ligament sprain
  • Medial elbow ligament injury
  • Tommy John injury
  • Medial collateral ligament (MCL) of the elbow injury
  • Tommy John Surgery

Background

History

  • First described by Waris in 1946[1]

Epidemiology

  • More common among junior high and college players than junior high[2]

Introduction

Classic mechanism of injury of the UCL[3]
Anatomy of the UCL[4]
(A) Anterior and (B) medial views of an elbow, demonstrating the 3 bundles of the ulnar collateral ligament (UCL) and the relationship between the anterior bundle of the UCL and the musculotendinous insertions of the flexor pronator mass, with the footprints represented by different colors. ABUCL, anterior bundle of the UCL; FCU, ulnar carpi ulnaris; FDS, flexor digitorum superficialis; OBUCL, oblique bundle of the UCL; PBUCL, posterior bundle of the UCL.[5]

General

  • The ulnar collateral ligament (UCL) is the primary stabilizer against valgus stress at the elbow
  • Injuries most commonly occur in overhead and throwing athletes and can be both acute and/or chronic
  • Most patients present with medial elbow pain worsened with throwing
  • The diagnosis is made with a history, physical exam and either MRI or Ultrasound
  • Nonoperative management is the initial strategy for most UCL tears

Pathophysiology

  • UCL functions as the primary elbow stabilizer to valgus stress
  • Throwing and overhead athletes produce reptitive valgus stress
  • Forces generated are significant
    • UCL is thought to fail at 34 Newtons
    • 68 N in tennis player serve[6]
    • Baseball players can generate 64 N
  • Chronic traction forces can lead to
    • UCL thickening and hypetrophy
    • Enthesiophyte at the ulna insertion
    • Fatigue of the common flexor tendon
  • UCL tear patterns[7]
    • 87%: torn at the midsubstance
    • 10%: avulsed distally from the ulna
    • 3%: avulsed proximally from the medial epicondyle

Mechanism of Injury

  • Chronic overuse
    • Microtrauma from repetitive valgus stress
  • Acute
  • Iatrogenic
    • Associated with medial elbow surgeries

Anatomy of the Ulnar Collateral Ligament (UCL)

Associated Injuries

Risk Factors

  • General
    • Height[8]
    • Long limb
  • Sports
    • Any overhead sports
    • Baseball (especially pitchers)
      • Increased pitching velocity[9]
      • Increased pitch count[10][11]
    • Tennis
    • Water polo
    • Volleyball
    • Golf
    • Wrestling
    • Track and field (especially javelin)
    • Football (quarterback)

Differential Diagnosis

Differential Diagnosis Elbow Pain

Clinical Features

Typical location of UCL pain
Demonstration of moving valgus stress test[12]

History

  • Important to characterize the onset of symptoms: acute, subacute or chronic
  • It is critical to characterize athletes level of participation, hand dominance, sports played, positions etc
  • Inquire about throwing style, ball velocity before and after the onset of elbow pain, throwing accuracy and phase(s) of throwing in which symptoms occur, types of pitches, pitch count, number of innings pitched,
  • Baseball: Pain most commonly during late cocking phase[7]
  • Tennis: Pain most commonly when the ball hits the racket
  • Most athletes complain of medial elbow pain during throwing or overhead activities[13]
    • Can be gradual or acute
    • Can be associated with a decline in performance including power, speed, accuracy, endurance
  • Sometimes accompanied by a sensation of locking or parethesias

Physical: Physical Exam Elbow

  • In acute injuries you may see swelling, bruising, tenderness
  • Focused palpation at the medial epicondyle, flexor tendon or UCL
    • Tenderness over the UCL: 81% to 94% sensitivity, 22% specificity for UCL tears[14]
  • Elbow range of motion should be performed, compared to the other side
  • Perform a comphrensive examination of the ulnar nerve

Special Tests

Evaluation

Right elbow MRI with contrast showing distal UCL injury and extravasation of contrast, forming the so called "T sign" (red arrow)[17]
Coronal images demonstrating differences in UCL tear location. A) T2-weighted coronal view of the elbow demonstrates a low-grade partial mid-substance tear (Grade 1) (arrow); B) T2-weighted coronal view of the elbow shows a high-grade partial distal tear (Grade 2) (arrow).[18]
Ultarsound of the UCL[19]
The normal anterior band of the ulnar collateral ligament is located by finding the hyperechoic bone contour of the medial epicondyle. The ligament is deep to the adjacent flexor tendon. The ulnar collateral ligament will appear hyperechoic and fibrillar. The humeroulnar joint space must be visible for dynamic testing of the ulnar collateral ligament integrity.[19]

Radiographs

  • Standard Radiographs Elbow
    • Frequently normal
    • May show avulsion fragment in acute injury
  • In chronic injuries, may see:
    • Ossification of the UCL
    • Loose bodies
    • Radiocapitellar and/or ulnohumeral osteophytes
  • Stress radiographs
    • Used to detect increased ulnohumeral gapping
    • Sensitivity ranges from 46% - 88%[15][20]
    • Gravity stress radiograph: AP radiograph with the patient supine, shoulder in maximum external rotation, forearm unsupported
    • Alternative technique: examiner applies a valgus load while the anteroposterior radiograph was obtained
    • There is a device that applies a uniform valgus stress may be used to obtain a stress radiograph
    • Manual and device stress views are not sufficiently sensitive for UCL injuries and not commonly used[15]
  • Comparison to non-dominant elbow may be helpful.
    • Joint space widening on stress radiographs > 0.5 mm in the affected elbow compared with the unaffected elbow indicated a significant partial tear or a complete tear of the UCL[21]
    • Athletes with widening less < 0.5 mm on stress radiographs compared with the normal elbow had a normal UCL or just a small tear that could be managed conservatively

CT

  • Not routinely used
  • CT Arthrogram would be study of choice
    • CT Arthrogram is 71% - 86% sensitive, 91% specific for UCL tears[14]

MRI

  • MRI without IV contrast
    • MRI without arthrogram: 57% - 79% sensitive, 100% specific for UCL tears[14]
  • MRI Arthrogram: 97% sensitive for UCL tears[15]
    • MRI Arthrogram considered gold standard for evaluating UCL injuries
    • Can also better evaluate other soft tissue injuries
  • Findings
    • Laxity
    • Irregularity
    • Poor definition
    • Increased signal intensity
  • Findings
    • Fluid extravasation
    • So called "T-sign"

Ultrasound

  • Normal UCL: appears as compact fibrillar echotexture, hyperechoic between the medial epicondyle and proximal ulna
  • Findings
    • In throwing athletes, especially pitchers, more likely to appear hypoechoic foci and/or calcifications and have laxity with valgus stress[22]
    • UCL Sprain: May demonstrate thickening, decreased echogenicity of the ligament, and surrounding hypoechoic edema[23]
    • Torn UCL: appear abnormally hypoechogenic, anechoic, and the fibers appear disrupted[24]
    • Pre-injury joint space is widened 1 - 1.5 mm on valgus stress in athletes who eventually developed a UCL tear[25]
  • Diagnostic performance[26]
    • Full thickness tears: sensitivity 79%, specificity 98%, accuracy 95%
    • Partial thickness tears: sensitivity 77%, specificity 94%, accuracy 90%
  • Dynamic stress evaluation
    • Further enhances diagnostic capabilities
    • Sensitivity of 96% and specificity of 81% for detecting a UCL injury
    • Findings suggestive of abnormal ulnohumeral joint laxity include a stress delta (change in joint space with valgus stress) of 2.4 mm or a side-to-side stress delta difference of 1 mm


Arthroscopy

  • Viewed through anterolateral portal, most notably the AOL
  • Partial (1 to 2 mm) and and full thickeness tears (4 to 10 mm) of the AOL can be visualized[27]
  • Timmerman et al: all patients with valgus instability on arthroscopy had AOL tears and all patients without valgus instability had intact, normal AOL on surgical exploration[14]

Classification

  • Strain
  • Low grade partial tear
  • High grade partial tear
  • Complete tear

Management

Hinged Elbow Brace

Ulnar collateral ligament (UCL) reconstruction with the novel anatomic UCL reconstruction technique. (A) The graft is fixed into a socket on the humerus via adjustable loop fixation. (B) All-suture suture anchors are placed in the ulna and (C) tied to secure the graft at the proximal UCL footprint. (C) A looped suture is used to run a whipstitch in the graft, and this suture is loaded onto a cortical button, (D) which is secured at the distal aspect of the native UCL footprint.[28]

Nonoperative

Procedures

  • Consider orthobiologics[30]
    • Platelet-rich plasma (PRP) injections have been described as an adjunct treatment
    • Particularly for partial or proximal tears, though robust clinical data supporting efficacy are currently lacking

Operative

  • Indications
    • Complete Rupture
    • Failure of conservative therapy for partial tears
    • High demand overhead athletse
  • Technique
    • MCL anterior band ligament reconstruction
    • Modified Jobe Technique
    • Docking Technique

Rehab and Return to Play

Nonsurgical Rehabilitation

  • Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow Score (KJOC score)
    • Used to evaluate performance in throwing athlete
    • Has been validated in athletes undergoing UCL reconstruction[31]
  • 2-phase Rehabilitation Protocol (Rettig et al)[32]
    • 42% of athletes able to return to pre-injury level of play at 24 months
    • Phase 1 (first 2-3 months)
      • No throwing, NSAIDs, icing for 10 minutes 4 times a day
      • Splint/brace at 90° at night and as needed for pain during the day,
      • Active and passive range of motion exercises for flexors and pronators
    • Phase 2 (3 months)
      • Discontinue the splint/brace
      • Begin progressive upper extremity strengthening program of all muscle groups
      • Begin a throwing progression
      • Use an Elbow Hyperextension Brace for throwing and lifting
  • Sport-Specific Biomechanical Corrections
    • Baseball pitchers
      • Modify mechanics to decrease degree of elbow stress
      • Improve: Late trunk rotation, reduced shoulder external rotation, increased elbow flexion, and overhand pitching[33]
      • Lower pitch count

Surgical Rehabilitation

  • Hariri et al Protocol[34]
    • Long term goal: maintain shoulder flexibility, strength (periscapular, rotator cuff, core)
    • Immediate postop: splint 70° to 90° of flexion at neutral forearm rotation
    • 10-day follow-up visit: splint is removed and active wrist, elbow, and shoulder range of motion exercises are initiated
      • Hinged elbow brace beginning at 30° to 100°
      • Biomechanical study: full extension and flexion up to 50° with further flexion straining the reconstruction[35]
      • Range of motion is progressed such that there should be full range of motion by 6 weeks
    • 4 to 6 weeks: athlete is progressed to strengthening exercises that avoid elbow valgus stress.
    • 8 weeks: elbow brace is removed
    • 14 to 16 weeks: throwing program is initiated
    • Program is progressed such that the average pitcher returns to play at approximately 10 months.
      • Other positions or sports may return sooner

Rehab Program PDFs

Return To Play: Nonsurgical

  • For sprains, low grade or high grade partial tears
    • May return to play after progressing through physical therapy pain free
    • Must complete a specific return-to-throwing protocol
  • Nonoperative management typically allows return to sport in 3 to 4 months for low-grade partial tears[36]
    • Longer, structured programs seem to improve outcomes

Return To Play: Surgical

  • Needs to be cleared by surgeon
  • Return-to-throwing programs typically begin at 16.7 weeks postoperatively[37]
    • Return-to-mound programs starting at 7.4 month
  • 82% of MLB pitchers return 18.5 months after Tommy John surgery without any major loss in output[38]

Prognosis and Complications

Prognosis

  • General nonoperative management
    • Overall return to play 79.7%, return to previous level of play 77.9%[39]
    • Proximal tears achieve 89.7% RTS compared to only 41.2% for distal tears
    • Outcomes are better with low/medium grade partial tears, complete tears often require surgery
  • Nonoperative management by sport
    • In professional baseball pitchers specifically, distal UCL tears show 12.4 times greater likelihood of failing nonoperative management[40]
    • Nonthrowing athletes have more favorable prognosis than overhead throwing athletes with nonoperative management[41]
  • Surgical management
    • UCL reconstruction demonstrates 80-90% return-to-play rate[42]
    • Most athletes return to full competition in 12-15 months, though professional pitchers often require 15-18 months
    • In nonthrowing athletes, UCL repair achieves 93% RTP at 7.4 months while reconstruction shows 100% RTP at 10.0 months[43]

Complications

See Also

Internal

External

References

  1. ↑ Waris W. Elbow injuries in javelin throwers. Acta Chir Scand 1946;93:563–75.
  2. ↑ Han KJ, Kim YK, Lim SK, et al. The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging. Clin J Sport Med 2009;19(4): 271–6.
  3. ↑ Image courtesy of clevelandclinic.org
  4. ↑ Zaremski, Jason L., Kevin R. Vincent, and Heather K. Vincent. "Elbow ulnar collateral ligament: injury, treatment options, and recovery in overhead throwing athletes." Current Sports Medicine Reports 18.9 (2019): 338-345.
  5. ↑ Frangiamore, Salvatore J., et al. "Qualitative and quantitative analyses of the dynamic and static stabilizers of the medial elbow: an anatomic study." The American Journal of Sports Medicine 46.3 (2018): 687-694.
  6. ↑ Elliott B, Fleisig G, Nicholls R, et al. Technique effects on upper limb loading in the tennis serve. J Sci Med Sport 2003;6(1):76–87.
  7. ↑ 7.0 7.1 Conway JE, Jobe FW, Glousman RE, et al. Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg Am 1992;74(1):67–83.
  8. ↑ Han KJ, Kim YK, Lim SK, et al. The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging. Clin J Sport Med 2009;19(4): 271–6
  9. ↑ Bushnell BD, Anz AW, Noonan TJ, et al. Association of maximum pitch velocity and elbow injury in professional baseball pitchers. Am J Sports Med 2010;38(4):728–32.
  10. ↑ Lyman S, Fleisig GS, Andrews JR, et al. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med 2002;30(4):463–8.
  11. ↑ Petty DH, Andrews JR, Fleisig GS, et al. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am J Sports Med 2004;32(5):1158–64.
  12. ↑ Ra’Kerry, K. Rahman, William N. Levine, and Christopher S. Ahmad. "Elbow medial collateral ligament injuries." Current reviews in musculoskeletal medicine 1.3 (2008): 197-204.
  13. ↑ Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  14. ↑ 14.0 14.1 14.2 14.3 Timmerman LA, Schwartz ML, Andrews JR. Preoperative evaluation of the ulnar collateral ligament by magnetic resonance imaging and computed tomography arthrography. Evaluation in 25 baseball players with surgical confirmation. Am J Sports Med 1994;22(1):26–31 [discussion: 32].
  15. ↑ 15.0 15.1 15.2 15.3 Azar FM, Andrews JR, Wilk KE, et al. Operative treatment of ulnar collateral ligament injuries of the elbow in athletes. Am J Sports Med 2000;28(1):16–23.
  16. ↑ Thompson WH, Jobe FW, Yocum LA, et al. Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 2001;10(2):152–7
  17. ↑ Nicolette, Guy W., and Jocelyn R. Gravlee. "Ulnar collateral ligament injuries of the elbow in female division I collegiate gymnasts: a report of five cases." Open access journal of sports medicine 9 (2018): 183.
  18. ↑ Beaudry, Mason F., et al. "Sex differences in elbow ulnar collateral ligament injuries: A retrospective analysis." Journal of Women's Sports Medicine 3.1 (2023): 14-24.
  19. ↑ 19.0 19.1 Manske, Robert C., et al. "The Use of MSK ultrasound in the evaluation of elbow ulnar collateral ligament injuries." International Journal of Sports Physical Therapy 18.2 (2023): 74018.
  20. ↑ Thompson WH, Jobe FW, Yocum LA, et al. Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 2001;10(2):152–7.
  21. ↑ Rijke AM, Goitz HT, McCue FC, et al. Stress radiography of the medial elbow ligaments. Radiology 1994;191(1):213–6.
  22. ↑ Nazarian LN, McShane JM, Ciccotti MG, et al. Dynamic US of the anterior band of the ulnar collateral ligament of the elbow in asymptomatic major league baseball pitchers. Radiology 2003;227(1):149–54.
  23. ↑ . Miller TT, Adler RS, Friedman L. Sonography of injury of the ulnar collateral ligament of the elbow-initial experience. Skeletal Radiol 2004;33(7):386–91.
  24. ↑ Jacobson JA, Propeck T, Jamadar DA, et al. US of the anterior bundle of the ulnar collateral ligament: findings in five cadaver elbows with MR arthrographic and anatomic comparison–initial observations. Radiology 2003;227(2):561–6.
  25. ↑ Ciccotti MG. Dynamic ultrasound of UCL. Presented at the Herodicus Society annual meeting, April 24, 2008.
  26. ↑ Thomas, Jonelle M., et al. "ACR Appropriateness Criteria® chronic elbow pain." Journal of the American College of Radiology 19.11 (2022): S256-S265.
  27. ↑ Field LD, Altchek DW. Evaluation of the arthroscopic valgus instability test of the elbow. Am J Sports Med 1996;24(2):177–81.
  28. ↑ Camp, Christopher L., et al. "Reconstruction of the medial ulnar collateral ligament of the elbow: biomechanical comparison of a novel anatomic technique to the docking technique." Orthopaedic Journal of Sports Medicine 7.7 (2019): 2325967119857592.
  29. ↑ Marcaccio, Stephen E., Justin W. Arner, and James P. Bradley. "Ulnar collateral ligament injuries in overhead athletes: diagnosis, management, and clinical outcomes." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 33.1 (2025): 14-22.
  30. ↑ Gopinatth, Varun, et al. "Return to sport after nonoperative management of elbow ulnar collateral ligament injuries: a systematic review and meta-analysis." The American Journal of Sports Medicine 51.14 (2023): 3858-3869.
  31. ↑ Domb BG, Davis JT, Alberta FG, et al. Clinical follow up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow Score (KJOC Score). Am J Sports Med 2010;38(8):1558–63.
  32. ↑ Rettig AC, Sherrill C, Snead DS, et al. Nonoperative treatment of ulnar collateral ligament injuries in throwing athletes. Am J Sports Med 2001;29(1):15–7.
  33. ↑ Aguinaldo AL, Chambers H. Correlation of throwing mechanics with elbow valgus load in adult baseball pitchers. Am J Sports Med 2009;37(10):2043–8. 42. Werner SL, Murray TA, Hawkins RJ, et al. Relationship between throwing
  34. ↑ Hariri, Sanaz, and Marc R. Safran. "Ulnar collateral ligament injury in the overhead athlete." Clinics in sports medicine 29.4 (2010): 619-644.
  35. ↑ Bernas GA, Ruberte Thiele RA, Kinnaman KA, et al. Defining safe rehabilitation for ulnar collateral ligament reconstruction of the elbow: a biomechanical study. Am J Sports Med 2009;37(12):2392–400.
  36. ↑ Carr, James B., Christopher L. Camp, and Joshua S. Dines. "Elbow ulnar collateral ligament injuries: indications, management, and outcomes." Arthroscopy 36.5 (2020): 1221-1222.
  37. ↑ Anderson, Matthew JJ, et al. "Return-to-competition criteria after ulnar collateral ligament reconstruction: a systematic review and meta-analysis." The American Journal of Sports Medicine 50.4 (2022): 1157-1165.
  38. ↑ Gibson BW, Webner D, Huffman GR, et al. Ulnar collateral ligament reconstruction in major league baseball pitchers. Am J Sports Med 2007;35(4):575–81.
  39. ↑ Gopinatth, Varun, et al. "Return to sport after nonoperative management of elbow ulnar collateral ligament injuries: a systematic review and meta-analysis." The American Journal of Sports Medicine 51.14 (2023): 3858-3869.
  40. ↑ Frangiamore, Salvatore J., et al. "Magnetic resonance imaging predictors of failure in the nonoperative management of ulnar collateral ligament injuries in professional baseball pitchers." The American Journal of Sports Medicine 45.8 (2017): 1783-1789.
  41. ↑ Herring, Stanley A., et al. "Initial assessment and management of select musculoskeletal injuries: a team physician consensus statement." Current Sports Medicine Reports 23.3 (2024): 86-104.
  42. ↑ Carr, James B., Christopher L. Camp, and Joshua S. Dines. "Elbow ulnar collateral ligament injuries: indications, management, and outcomes." Arthroscopy 36.5 (2020): 1221-1222.
  43. ↑ Rothermich, Marcus A., et al. "Clinical outcomes of ulnar collateral ligament surgery in nonthrowing athletes." The American Journal of Sports Medicine 50.12 (2022): 3368-3373.
  44. ↑ Andrews JR. Complications of ulnar collateral ligament reconstruction. Presented at the International Society of Arthroscopy, Knee Surgery and Orthopedic Sports Medicine (ISAKOS). Florence (Italy), May 30, 2007
  45. ↑ Pezzulo, Joshua, et al. "Evolution of the surgical treatment of ulnar collateral ligament injuries." Arthroscopy 40.12 (2024): 2780-2782.
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John Kiel on 18 June 2019 01:54:00
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