What are the treatment options for UCL tears of the elbow in - - PowerPoint PPT Presentation

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

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Clinical Question

• In the athleGc populaGon, what are the

treatment opGons for paGents with an ulnar collateral ligament tear of the elbow, who wish to return to normal physical acGvity?

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Overhead Throwing

• Results in significant valgus

stress to the elbow

• Stress concentrated on

medial structures

• Majority of injuries

secondary to repe$$ve

• verload 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

• SoZ Gssue restraints provide primary staGc and

dynamic stability from 20-120° = arc of moGon of

• verhead 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 acceleraGon 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 acceleraGon, Compressive force

• f 500 N lateral radiocapitellar

arGculaGon 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 akenuaGon/tears
• Olecranon Gp osteophytes
• Loose bodies
• Flexor-pronator mass tendoniGs
• Ulnar neuriGs
• Medial epicondyle apophysiGs 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:

InspecGon: effusion, carrying angle (nl 11° valgus ♂, 13° ♀, adapGve changes in

throwers can increase, assess deformity from prior trauma)

ROM: acGve, passive (sagital 0-140°±10°, 80-90° pronaGon and supinaGon, assess for

contracture, compensaGon w/ shoulder) Flexion contracture present in 50% of pitchers, End points: soZ in flexion, firm bone on bone in extension

PalpaGon: bony landmarks: medial epicondyle, radial head, Gp of olecranon; SoZ

Gssues: biceps, triceps, flexor-pronator mass, UCL; neurovascular structures Strength TesGng

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 calcificaGon, OCD of capitellum, loose bodies

• CT Scan: olecranon stress fx
• Bone Scan: olecranon stress fx
• MRI vs CT arthrogram: UCL evaluaGon
• 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.

Ciccop et al.

Evaluation of Valgus Instability: History

• Acute Injury:

▪ sudden onset of pain aZer throwing ± pop

▪ unable to conGnue throwing

• Chronic Injury:

▪ gradual onset of localized medial elbow pain during late-cocking or acceleraGon

▪ pain aZer episode of heavy throwing w/ subsequent inability to throw at more than 50-70% of nl level ▪ ulnar nerve symptoms 2° to irritaGon from local inflammaGon

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
• pening to contralateral

side

• Loss of firm endpoint w/

increased medial joint- space opening → akenuated 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
• n flexed elbow
• SubjecGve feeling of

apprehension and instability + localized medial elbow pain indicates UCL injury

Moving Valgus Stress Test

• Pain from 70 -120
• 100% SensiGve
• 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 moGon w/ loss of terminal

extension secondary to flexion contracture may be present w/ chronic valgus instability

Radiographic Findings

• CalcificaGon and
• ccasional ossificaGon 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
• pening suggesGve

Langer et al. Br J Sports Med. 2006;40:499-506.

Usefulness of MRI vs CT arthrogram

• Nonenhanced MRI vs CT arthrogram in 25 paGents w/

surgically confirmed UCL injury MRI CT arthrogram SensiGvity 57% 86% Specificity 100% 91% Both 100% sensiGvity for complete tears

• Saline-enhanced arthrogram MRI

SensiGvity 92% (95% for complete tear, 86% for parGal) Specificity 100%

Treatment Options

• ConservaGve

– Therapy – PRP

• Surgical

– Acute Repair – Chronic ReconstrucGon

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PubMed Search

• Elbow Ulnar Collateral Ligament Injury
• 301 ArGcles
• No good Level I or II studies

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Conservative Options

• Non opera3ve treatment is indicated in non-

throwers, and has acceptable results in this lower- demand popula3on

• Rehab 2-3 month of non-throwing, splin3ng un3l

pain improved and ROM and PT of the shoulder

• Injec3on of the UCL with cor3costeroid should be

avoided

Langer et al. Br J Sports Med. 2006;40:499-506.

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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 .

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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.

• Repg et al found 42% RTP avg of 24.5 weeks

aZer diagnosis (Mean age 18)

Repg et al. Am J Sports Med. 2001 Jan-Feb;29(1):15-7

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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 Gme 12 weeks) – 1 went on to surgery

Podesta et al. Am J Sports Med. 2013 Jul;41(7):1689-94.

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UCL Direct Ligament Repair

• ONLY in acute traumaGc rupture without

dislocaGon.

• 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

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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 paGents 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
• f play within 6 months.

Savoie et al. Am J Sports Med 2008.

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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 ReconstrucGon Group

• Major League Players Returning

– 2/7 Repair Group – 12/16 ReconstrucGon Group

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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.

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UCL Ligament Reconstruction

• 1986 Jobe et al.
• Figure of eight graZ
• All throwers
• 10/16 returned to play

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Docking Technique

• 1996 Described by

Altchek

• Rohrbough et al

reported 92% RTP for at least one year

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University of Pennsylvania Department of Orthopaedic Surgery

Post-operative Rehabiltation

• Brief ImmobilizaGon 7-10 days, followed by AAROM

and AROM

• Hinged brace- 5 weeks aZer splint, 20-140 degrees
• Progressive resisGve strengthening exercises of wrist

and forearm 4-6 wks

• At 6 weeks begin elbow strengthening exercises
• Avoid valgus stress unGl 4 months
• Throwing program beginning at 4 months
• CondiGoning of shoulder and elbow progress w/

return to pre-injury acGvity by 12-18 months

Clinical Conclusions

• Injury to the medial collateral ligament of the

elbow is rela3vely common in athle3cs.

• Appropriate clinical exam and diagnos3c studies

should be u3lized.

• Conserva3ve treatment and rehabilita3on

should be considered for injuries that have no significant laxity on exam in a non-thrower.

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Clinical Conclusions

• Surgical treatment has good outcomes for

pa3ents with valgus laxity.

• Decreased dissec3on of the flexor pronator

mass leads to beSer outcomes

• Decreased handling of the ulnar nerve leads to

beSer outcomes

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Bottom Line

• Injury to the UCL can have a significant impact

normal func3on of the elbow. This is even more important in the throwing athlete.

• It is important to iden3fy subtle instability and

implement an appropriate course for treatment.

– Par3al tears, ultrasound capabili3es

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Thank you!

Interference Technique

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References

• Am J Sports Med. 2013 Jul;41(7):1689-94. doi:

10.1177/0363546513487979. Epub 2013 May 10. Treatment of parGal 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 ContribuGons 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
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• 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 IdenGfied by Stress Ultrasound of the Elbow in Young Professional Baseball Pitchers. Atanda A Jr1, Buckley PS2, Hammoud S2, Cohen SB2, Nazarian LN3, Ciccop MG2.

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• 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

• f the ligament. SavoieFH, Trenhaile SW, Roberts

J, Field LD, Ramsey JR.

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• J Shoulder Elbow Surg. 2000 Jan-Feb;9(1):1-5.

Acute elbow injuries in the NaGonal 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.

NonoperaGve treatment of ulnar collateral ligament injuries in throwing athletes. Repg AC, Sherrill C, Snead DS, Mendler JC, Mieling P.

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• Radiology. 1995 Oct;197(1):297-9. Ulnar

collateral ligament injury in the throwing athlete: evaluaGon with saline-enhanced MR

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Morwessel RM, Andrews JR.

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• Am J Sports Med. 1994 Jan-Feb;22(1):26-31;

discussion 32. PreoperaGve evaluaGon of the ulnar collateral ligament by magneGc resonance imaging and computed tomography

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with surgical confirmaGon. Timmerman LA1, Schwartz ML, Andrews JR.

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• J Bone Joint Surg Am. 2009 Oct 1;91 Suppl

2:191-9. doi: 10.2106/JBJS.I.00426. TraumaGc valgus instability of the elbow: pathoanatomy and results of direct repair. Surgical technique. Richard MJ, Aldridge JM 3rd, Wiesler ER, Ruch DS.

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• 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

• f 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 reconstrucGon
• f 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.

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• Br J Sports Med. 2006;40:499-506. EvoluGon of

the treatment opGons 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 reconstrucGon of the elbow using the docking technique. Rohrbough JT1, Altchek DW, Hyman J, Williams RJ 3rd, Boks JD.

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• J Ultrasound Med. 2015 Mar;34(3):371-6. doi:

10.7863/ultra.34.3.371. Reliability and precision

• f stress sonography of the ulnar collateral
• ligament. Bica D1, Armen J2, Kulas AS2, Youngs

K2, Womack Z2.

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