Ulnar collateral ligament injury

Location of UCL injury
Pronating forearm
Supination exercise

Ulnar collateral ligament injuries They can be classified into two categories: a slow deterioration or an acute rupture.

The ulnar collateral ligament (UCL, also known as medial collateral ligament) is located on the medial side of the elbow. The UCL complex comprises three ligaments: the anterior oblique, posterior oblique and transverse ligaments.[1] The anterior oblique ligament (AOL) attaches from the undersurface of the medial epicondyle to the medial ulnar surface slightly below the coronoid process.[2] It is the sturdiest of the three sections within the UCL. The AOL acts as the primary restraint against valgus stress at the elbow during flexion and extension. The posterior oblique originates at the medial epicondyle and inserts along the mid-portion of the medial semilunar notch.[1] It applies more stability against valgus stress when the elbow is flexed rather than extended. The transverse ligament connects to the inferior medial coronoid process of the ulna to the medial tip of the olecranon.[1] Since it is connected to the same bone and not across the elbow joint, the transverse ligament has no contribution to the joint’s stability.

Classification

A slow and chronic deterioration of the ulnar collateral ligament can be due to repetitive stress acting on the ulna. At first, pain can be bearable and can worsen to an extent where it can terminate an athlete’s career. The repetitive stress placed on the ulna causes micro tears in the ligament resulting in the loss of structural integrity over time.[3] The acute rupture is less common compared to the slow deterioration injury. The acute rupture occurs in collisions when the elbow is in flexion such as that in a wrestling match or a tackle in football. The ulnar collateral ligament distributes over fifty percent of the medial support of the elbow.[4][5] This can result in an ulnar collateral ligament injury or a dislocated elbow causing severe damage to the elbow and the radioulnar joints.

Causes

The UCL is important because it stabilizes the elbow from being abducted. If intense or repeated bouts of valgus stress occur on the UCL, injury will most likely transpire. Damage to the ulnar collateral ligament is common among baseball pitchers and javelin throwers because the throwing motion is similar. Gridiron football, racquet sports, ice hockey and water polo players have also been treated for damage to the ulnar collateral ligament.[6][7] Specific overhead movements like those that occur during baseball pitching, tennis serving or volleyball spiking increase the risk of UCL injury.[8] During the cocking phase of pitching, the shoulder is horizontally abducted, externally rotated and the elbow is flexed. There is slight stress on the UCL in this position but it increases when the shoulder is further externally rotated. The greater the stress the more the UCL is stretched causing strain. However, the majority of valgus stress occurs during the acceleration phase of pitching. In this phase, the body is brought forward leaving the arm to follow.[2] Then, the shoulder is forcefully internally rotated, whipping the humerus forward which leaves the forearm behind. This causes tremendous valgus stress and tensile strain on the UCL. Injuries to the ulnar collateral ligament are believed to result from poor throwing mechanics, overuse, high throwing velocities, and throwing certain types of pitches, such as curveballs.[9] Poor mechanics along with high repetition of these overhead movements can cause irritation, micro-tears or ruptures of the UCL. Injuries to the Ulnar Collateral Ligament in baseball players are rarely due to one-time, traumatic events. Rather, they are more often due to small chronic tears that accumulate over time.

Epidemiology

According to the International Classification of Diseases, 9th Revision, Clinical Modification, ICD-9-CM, in 2008 the U.S. listed the diagonsis code for UCL injury as 841.1: Sprain ulnar collateral ligament. There were a total of 336 discharges of UCL injuries. Within the total discharges, separated by age groups: 18- to 44-year-olds; 165 people (49.17%). 45- to 64-year-olds; 91 (27.08%). 65- to 84-year-olds, 65 (19.35%) it shows that the ulnar collateral ligament injuries were more commonly found in men than women. There were 213 men compared to 123 women with ulnar collateral ligament injury. Most of these injuries were also paid through private insurance (170: 50.63%) and Medicare (70: 20.85%).[10] The average estimated cost for the surgery also known as Tommy John surgery is $21,563.[11]

Diagnosis

In most cases, a physician will diagnose an ulnar collateral ligament injury using a patient’s medical history and a physical examination that includes a valgus stress test. The valgus stress test is performed on both arms and a positive test is indicated by pain on the affected arm that is not present on the uninvolved side.[12][13] Physicians often utilize imaging techniques such as ultrasound, x-rays and magnetic resonance imaging or arthroscopic surgery to aid with making a proper diagnosis.

Signs and symptoms

Pain along the inside of the elbow is the main symptom of this condition. Throwing athletes report it occurs most often during the acceleration phase of throwing. Closing the hand and clenching the fist has also been shown to reproduce the painful symptoms.[14] The injury is often associated with an experience of a sharp “pop” in the elbow, followed by pain during a single throw.[15] In addition, swelling and bruising of the elbow, loss of elbow range of motion, and a sudden decrease in throwing velocity are all common symptoms of a UCL injury. If the injury is less severe, pain can be minimal with complete rest.[16]

Grip strengthening exercises

Treatments

UCL injuries may or may not require surgery. Non surgical treatment will primarily focus on strengthening the elbow joint to regain strength and stability.[17] First a course of RICE (Rest, ice, compression, elevation) is typically coupled with NSAIDS (Non-steroidal anti-inflammatory drugs) to help alleviate pain and swelling. When the swelling has subsided, individual exercises or physical therapy may be prescribed to strengthen muscles around the elbow joint to compensate for tearing in the UCL ligament.[17] These may include biceps curls (non resistance and resistance), pronating and supinating the forearm, and grip strengthening exercises, performed with low resistance and moderate repetitions no more than three times a week.[18]

Surgical treatment may help restore the ability to perform the overhand throwing motions most commonly associated with UCL injuries. Typically, the reconstructive surgery, generally known as Tommy John surgery, will involve an autograft of the palmaris longus tendon (mostly seen as an accessory tendon) or an allograft of tissue from a cadaver or donor. The new tendon is attached by drilling holes in the medial epicondyle of the humerus and the sublime tubercle of the ulna and lacing the tendon through them in a figure eight.[19][20] The patient may begin physical therapy shortly after.

The tendon chosen is then woven in a figure eight pattern through the humerus and ulna, which holes were first drilled in the bones.[21] After surgery occurs, rehabilitation comes into place and usually takes about a year because a tendon needs time to convert into a ligament.[22]

References

  1. 1 2 3 Safran, Marc; Ahmad, Christopher S.; Elattrache, Neal S. (2005). "Ulnar Collateral Ligament of the Elbow". Arthroscopy 21 (11): 1381–95. doi:10.1016/j.arthro.2005.07.001. PMID 16325092.
  2. 1 2 Zarins, Bertram; Andrews, James Rheuben; Carson, William George (1985). Injuries to the throwing arm: based on the proceedings of the national conference. Philadelphia: Saunders. ISBN 0-7216-1416-7.
  3. ↑ Morrey, Bernard F.; An, Kai-Nan (1983). "Articular and ligamentous contributions to the stability of the elbow joint". The American Journal of Sports Medicine 11 (5): 315–9. doi:10.1177/036354658301100506. PMID 6638246.
  4. ↑ Hotchkiss, Robert N.; Weiland, Andrew J. (1987). "Valgus stability of the elbow". Journal of Orthopaedic Research 5 (3): 372–7. doi:10.1002/jor.1100050309. PMID 3625360.
  5. ↑ Maloney, Michael D.; Mohr, Karen J.; El Attrache, Neal S. (1999). "Elbow injuries in the throwing athlete. Difficult diagnoses and surgical complications". Clinics in Sports Medicine 18 (4): 795–809. doi:10.1016/S0278-5919(05)70185-X. PMID 10553236.
  6. ↑ http://www.athleticadvisor.com/Injuries/UE/ucl_injuries.htm[]
  7. ↑ Mirowitz, S A; London, S L (1992). "Ulnar collateral ligament injury in baseball pitchers: MR imaging evaluation". Radiology 185 (2): 573–6. doi:10.1148/radiology.185.2.1410375. PMID 1410375.
  8. ↑ Hariri, Sanaz; Safran, Marc R. (2010). "Ulnar Collateral Ligament Injury in the Overhead Athlete". Clinics in Sports Medicine 29 (4): 619–44. doi:10.1016/j.csm.2010.06.007. PMID 20883901.
  9. ↑ http://carlykreps.tripod.com/tommyjohn/id3.html[][]
  10. ↑ U.S. Department of Health & Human Services: Agency for Healthcare Research and Quality - Advancing Excellence in Health Care. http://hcupnet.ahrq.gov/HCUPnet.jsp.
  11. ↑ Ulnar Collateral Ligament Reconstruction Surgery Cost. http://www.surgerycosts.net/price.php?medical=ulnar-collateral-ligament-reconstruction-surgery.
  12. ↑ http://at.uwa.edu/Special%20Tests/SpecialTests/UpperBody/elbow%20Main.htm[]
  13. ↑ O'Driscoll, Shawn W. M.; Lawton, Richard L.; Smith, Adam M. (2005). "The 'Moving Valgus Stress Test' for Medial Collateral Ligament Tears of the Elbow". The American Journal of Sports Medicine 33 (2): 231–9. doi:10.1177/0363546504267804. PMID 15701609.
  14. ↑ Sechrest, Randale C. (2009). "Ulnar collateral ligament injuries". eOrthopod. Medical Multimedia Group.
  15. ↑ Ulnar Collateral Ligament Injury at eMedicine
  16. ↑ Anderson, Barton (2010). "Ulnar collateral ligament sprain". Sports Injury Info.
  17. 1 2 http://www.hopkinsortho.org/ucl.html[]
  18. ↑ Ulnar Collateral Ligament Injury~treatment at eMedicine
  19. ↑ http://www.athleticadvisor.com/injuries/UE/ucl_injuries.htm[]
  20. ↑ http://www.hopkinsortho.org/ucl.html[]
  21. ↑ Bernas, G. A.; Ruberte Thiele, R. A.; Kinnaman, K. A.; Hughes, R. E.; Miller, B. S.; Carpenter, J. E. (2009). "Defining Safe Rehabilitation for Ulnar Collateral Ligament Reconstruction of the Elbow: A Biomechanical Study". The American Journal of Sports Medicine 37 (12): 2392–400. doi:10.1177/0363546509340658. PMID 19684292.
  22. ↑ Ellenbecker, Todd S.; Mattalino, Angelo J. (1997). The elbow in sport: injury, treatment, and rehabilitation. Champaign, IL: Human Kinetics. ISBN 0-87322-897-9.
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