what are the treatment options for ucl tears of the elbow
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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


  1. 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

  2. Disclosures • President and Founder of LibraryOfMedicine.com www.UOANJ.com

  3. 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? www.UOANJ.com

  4. 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

  5. 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 overhead throwing

  6. 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

  7. Stages of Overhead Throwing

  8. Obviously Confused…

  9. Biomechanics of Throwing Generates large valgus and • extension forces Valgus force as high as 64 Nm at • late cocking and early acceleraGon, Compressive force of 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

  10. Spectrum of Injury • UCL akenuaGon/tears • Olecranon Gp osteophytes • Loose bodies • Flexor-pronator mass tendoniGs • Ulnar neuriGs • Medial epicondyle apophysiGs in skeletally immature

  11. 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

  12. 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

  13. 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.

  14. 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

  15. 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 → akenuated or incompetent UCL

  16. 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 • SubjecGve feeling of apprehension and instability + localized medial elbow pain indicates UCL injury

  17. 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

  18. 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

  19. Radiographic Findings • CalcificaGon and occasional 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 opening suggesGve Langer et al. Br J Sports Med. 2006;40:499-506.

  20. 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%

  21. Treatment Options • ConservaGve – Therapy – PRP • Surgical – Acute Repair – Chronic ReconstrucGon www.UOANJ.com

  22. PubMed Search • Elbow Ulnar Collateral Ligament Injury • 301 ArGcles • No good Level I or II studies www.UOANJ.com

  23. 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. www.UOANJ.com

  24. 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

  25. 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 www.UOANJ.com

  26. 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. www.UOANJ.com

  27. 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 www.UOANJ.com

  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 • 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 of play within 6 months. Savoie et al. Am J Sports Med 2008. www.UOANJ.com

  29. 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 www.UOANJ.com

  30. 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

  31. UCL Ligament Reconstruction • 1986 Jobe et al. • Figure of eight graZ • All throwers • 10/16 returned to play www.UOANJ.com

  32. Docking Technique • 1996 Described by Altchek • Rohrbough et al reported 92% RTP for at least one year www.UOANJ.com

  33. 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 University of Pennsylvania Department of Orthopaedic Surgery

  34. 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. www.UOANJ.com

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