Patient
Guide to Ulnar Collateral Ligament (UCL) Injuries of the Elbow
What
is the Ulnar Collateral Ligament?
A
ligament is a structure that holds bones together and helps to
control the movement of joints.
The
best way to think of a ligament is as a tether between the bones,
which gets too tight when the bones move. When a ligament is torn,
the tether is too long and the bones move too much. This can lead
to pain, a sense of instability or looseness, and inability to
work or do your sport. The ulnar collateral ligament complex (UCL)
is located on the inside (or medial side) of the elbow (small
finger side of the arm). It is composed of three bands or divisions,
the anterior, posterior, and transverse bands. The UCL attaches
on one side to the humerus (the bone of the upper arm) and on
the other to the coronoid process of the ulna (a bone in the forearm)
(Figure 1).
Of
the three bands in the UCL, the anterior band of the UCL is the
arm’s primary restraint from stress to the elbow, while the
posterior and transverse bands do less to stabilize the elbow.
The largest stresses in the elbow are those forces that cause
twisting and bending of the elbow, such as the throwing of a baseball
or javelin. These motions put extreme stress on the ligament during
certain parts of the motion.
How
is the UCL injured, and what are the symptoms?
The
UCL can be injured in several different ways. Most commonly, there
is a gradual onset of medial elbow pain due to repetitive stresses
on the ligament. For athletes participating in overhead or throwing
sports, poor mechanics, inflexibility, or fatigue can eventually
lead to muscle strain, which places more stresses on the UCL.
These stresses create microscopic tears in the ligament, which
can add up to one big tear over time. (Figure 2) This gradual
stress causes the ligament to stretch and become too long. Once
it gets too long, it no longer holds the bones tightly enough
during throwing activities.
Occasionally,
throwing athletes may experience a sharp "pop" or develop
sharp pain along the inside of the elbow joint on one particular
throw leading to the inability to continue throwing. Pain on the
inside of the elbow may also be felt after a period of heavy throwing
or other overhead activity, or the athlete may be unable to throw
beyond 50% to 75% on successive attempts. Pain is usually felt
during the phase of throwing in which the arm accelerates forward,
just prior to releasing the ball. Occasionally the athlete may
get irritation of the ulnar nerve ("funny bone" nerve)
on the medial side of the elbow. This is due to stress on the
nerve once the ligament is stretched and is felt as tingling or
numbness in the last two fingers (small and ring fingers) in the
hand.
While
the instability resulting from a tear of the UCL may inhibit the
ability to participate in throwing sports, it is unlikely to impair
the activities of daily living, such as carrying a bag of groceries.
Interestingly, a tear of the UCL rarely prevents exercising, lifting
weights, batting, running, or other non-throwing sports.
How
is a tear of the UCL diagnosed?
A
tear of the ulnar collateral ligament can often be diagnosed by
a physician through a history and physical examination. A valgus
stress test, in which the physician tests the patient’s elbow
for instability, is the best way for the physician to assess the
condition of the UCL (Figure 3). A magnetic resonance (MRI) scan
and x-ray may also be done to further assess the condition of
the structures in the patient’s elbow, but these tests are
not the sole basis for a diagnosis. These tests often demonstrate
changes in the ligament indicating it has been under stress, which
is common in throwing athletes. Sometimes it will show a definite
tear in the ligament, but often times a MRI will not make the
diagnosis completely. Injecting dye (gadolinium) into the joint
before the MRI sometimes increases its accuracy. The most difficult
part of treating a UCL problem is making the diagnosis. This is
because the examination is often inexact and the tests are not
100% accurate.
What
are the options if I have a UCL tear?
The
treatment options following a UCL tear depend primarily on the
patient’s goals. If joint stability and pain relief is the
patient’s main goals, then non-surgical treatment is usually
adequate. But, if the patient wishes to return to strenuous overhead
or throwing activities and they do not respond to non-surgical
treatments, then surgical repair of the UCL is recommended. Once
the ligament has torn, it does not really heal well enough to
allow a return to throwing.
Non-Surgical
Treatment
The
goal of non-operative treatment of a torn UCL is to restore stability
to the elbow joint and provide pain relief to the patient. Treatment
consists of an initial period of rest along with taking non-steroidal
anti-inflammatory medications (like aspirin, ibuprofen, naproxen,
etc.) and applying ice to the elbow daily until the pain and swelling
are gone. After inflammation of the elbow has decreased, the patient
may begin physical therapy. The purpose of the physical therapy
is to strengthen the muscles around the elbow to compensate for
the torn ligament.
Surgical
Treatment
There
are two types of surgical treatments used in dealing with a torn
UCL:
(1)
Repair of the existing ligament or (2) replacement (reconstruction)
of the ligament. However, direct repair of the existing ligament
is only performed when the ligament has pulled away from its humeral
attachment. This is known as an "avulsion" and is rare.
More commonly, the torn UCL must be replaced with a tendon "graft."
The material used to reconstruct the ligament is called a graft.
The ligament is reconstructed using a tendon most commonly taken
from the patient’s wrist and forearm (an accessory tendon
called the palmaris longus tendon).
The
most commonly used material is a tendon from the patient’s
own body (autograft) but in rare instances the ligament is reconstructed
with a donor (cadaver) tendon called an allograft. Other tendons
that can be used include forearm tendons (half of the flexor carpi
radialis), toe tendons (one toe tendon which goes to the big toe
- it has two), a hamstring tendon, or part of the Achilles tendon.
There are advantages and disadvantages to all of these, and they
are used because some people do not have a palmaris longus tendon
in their forearm. Approximately 15-18 cm of tendon is needed to
reconstruct the UCL. Several small incisions are made in the patient’s
forearm to extract the tendon.
The
surgery is usually done with a nerve block of the arm so that
it is completely numb. A 10-cm incision is made on the inside
of the patient’s elbow. To expose the anterior band of the
UCL, the flexor-pronator muscle mass is split lengthwise. This
muscle-splitting approach is less traumatic to the muscle than
detaching the muscle from the bone, and may allow the patient
to recover faster and with less pain. However, sometimes it is
necessary to release the muscles to get more exposure; the muscles
are re-attached and the recovery is still excellent with no known
bad effects. Tunnels are then drilled in the ulna and humerus
at the site of attachment of the original anterior band of the
UCL. The graft is then passed through these tunnels to form a
figure-of-eight, thus reconstructing the ligament. (Figure 4)
Any remnants of the patient’s original ligament are sutured
into the graft to give it added strength.
How
long does rehabilitation take after surgery?
The
postoperative rehabilitation program begins immediately following
surgery and is divided into three phases (see Rehabilitation After
UCL Reconstruction).
Following
surgery, the patient is placed in a splint for seven to ten days
to immobilize the elbow and allow the wound to heal. During this
ten day period, gentle wrist, hand, and shoulder range of motion
exercises are performed. After this initial period, a range of
motion brace is utilized to gradually allow the patient to regain
full range of motion in the elbow joint. Throughout phase I, shoulder
and arm strengthening, as well as total body conditioning exercises
are performed.
During
phase II, full range of motion is restored and wrist and forearm
strengthening exercises are begun. At about six weeks after surgery,
elbow strengthening exercises may begin, but stresses to the elbow
which might overstress the graft should be avoided for four months.
Phase
III consists of a sport-specific strengthening program. Throwing
athletes may begin to toss a ball without a wind-up motion 4-5
months after surgery. At 6 months postoperative, the patient may
begin to use an easy wind-up from flat ground while continuing
to increase throwing distance, and at 7 months baseball pitchers
may return to the mound. Throwing in competition is allowed after
nine moths if the patient is pain-free and has regained normal
strength and range of motion. Some individuals may progress more
rapidly than this but it must be done with caution.
A
patient’s rehabilitation is monitored closely by both the
physical therapist and the physician. Particular attention is
paid to an athlete’s throwing mechanics to limit the amount
of stress placed upon the elbow. Also, patients are cautioned
not to attempt to accelerate the rehabilitation period. The graft
must be given adequate time to be incorporated into the body.
Too much stress on the graft before it has healed increases the
risk of failure.
What
are the results of surgery?
Approximately
75-85 percent of athletes return to their previous level of competition
following reconstruction of the UCL. Some baseball pitchers even
report increased velocity after surgery. The average rehabilitation
time for throwing athletes is about 1 year, but it may take up
to 24 months for a patient to return to their previous ability
level.
What
are the potential problems of surgery?
The
most common complications following surgery involve the nerves
in the elbow, but fortunately these are uncommon with modern techniques.
Ulnar nerve symptoms are the most common problem, and it is usually
just tingling and numbness which goes away shortly after surgery.
Nerve impairments usually can be corrected by re-operation if
necessary.
Stretching
or even a rupture of the graft is possible but very uncommon.
In these cases, a new graft may be used to perform a second reconstruction.
Potential
complications may also arise from the graft harvesting site, but
these too are rare. These can usually be resolved with medication.
Personal
Experience with UCL Reconstruction by Eric Eisner
As
an eighteen year-old college freshman, the last thing I wanted
to hear was that I had torn the ulnar collateral ligament in my
pitching elbow. Not being able to play baseball in my first year
at Hopkins was hard to deal with. However, thanks to modern surgical
techniques I was able to return to pitching the following season.
In fact, I was able to throw harder than before I had "Tommy
John Surgery."
Prior
to surgery I worked hard to strengthen the muscles in my forearm
and biceps. I believe this helped me to stay on-track with the
prescribed rehabilitation schedule, which kept me optimistic about
my return to pitching. The first few weeks of my rehab included
stretching exercises and some light shoulder work. This period
went by very fast, with surprisingly little discomfort. After
regaining full range-of-motion, I was ready to begin re-strengthening
the muscles in my forearm and biceps. This was the most frustrating
period of my rehab because I could feel the strength coming back
to my arm, but I was unable to apply any stress to my elbow. Finally,
after four months I was able to begin throwing again. I can still
remember the first throw I made, all ten feet of it. I can honestly
say that I have never been more nervous about any one throw. Needless
to say, that first throw went well and I was free to enter the
final phase of my rehabilitation. About seven months after the
surgery I was able to begin throwing with an easy wind-up and
was soon long-tossing. The only snag I had during my rehab occurred
about two months into the long-toss and pitching phase of the
program. I can definitely attribute this problem to trying to
throw too hard too soon. I cannot stress enough the importance
of going slow during the entire rehab process. Have confidence
that you will reach the next step in the program when your arm
is ready. After being idle for about two weeks, I slowly returned
to the rehab program, making sure that my arm was ready before
I progressed to the next level.
While
some people may be ready to pitch competitively in as few as nine
months after surgery, it took me about a year before I was completely
ready. In terms of pitching, arm strength definitely returns before
control and feel. Also, it took many hours of working out with
Philadelphia Phillies pitcher Randy Wolf to smooth out my mechanics.
Before my injury, I took my mechanics for granted, but during
my rehab I found that the only way to be successful is to have
a flawless pitching motion. Most importantly, I noticed that I
was able to throw harder than before I injured my elbow. To actually
have more velocity on my fastball than I did before my injury
not only amazed me, it also provided me with the confidence needed
to overcome any doubts I had upon my return to competitive pitching.
About
the Author: Eric Eisner is a Johns Hopkins University Undergraduate
student who aspires to be a physician and to throw 95mph. He is
currently applying to medical school and plays baseball for the
Johns Hopkins University Blue Jays.
References
-
McFarland
EG, Cosgarea AJ, Sherbondy PS: Valgus Elbow Instability in
Athletes. Biomechanics: Figures 1-5, December 1999
-
Jobe
FW, El Attrache NS: Treatment of Ulnar Collateral Ligament
Injuries in Athletes
-
Conway
JE, Jobe FW, Glousman RE, Pink M: Medial Instability of the
Elbow in Throwing Athletes. Journal of Bone and Joint Surgery
74: 61-83, 1992
-
Azar
FM, Andrews JR, Wilk KE, Groh P: Operative Treatment of Ulnar
Collateral Ligament Injuries of the Elbow in Athletes. American
Journal of Sports Medicine 28: 16-23, 2000
-
Andrews
JR, Timmerman LA: Outcome of Elbow Surgery in Professional
Baseball Players. American Journal of Sports Medicine 23:
407-413, 1995.
-
Timmerman
LA, Schwartz ML, Andrews JR: Preoperative Evaluation of the
Ulnar Collateral Ligament by Magnetic Resonance Imaging and
Computed Tomography Arthrography. American Journal of Sports
Medicine 22: 26-32, 1994
