Sports Medicine Approach to Ulnar Collateral Ligament Injuries Bob Crawford, MD CAQSM CrawforR@SummaHealth.org Summa Center for Sports Health/Summa Orthopaedic Institute Team Physician Kent State University Team Physician Akron Rubber Ducks Team Physician Wadsworth High School Offices in Wadsworth and Medina

Reviewing Key Points Static stabilizers (3 bundles) Anterior bundle of the UCL provides valgus stability through the entire ROM. Greatest from extension to 90°. The posterior bundle assists as flexion increases Dynamic stabilizers Flexor pronator mass (5 muscles) Late cocking and early acceleration phase causes maximal valgus stress Sports Medicine

Overhead Sports Injuries Baseball Softball Football Tennis Volleyball Javelin Jai alai Racquetball Handball Squash Cricket Other Differential Diagnosis of medial athletic elbow injuries Medial UCL tears Ulnar neuritis Flexor-pronator injuries Medial epicondyle apophysitis or avulsion Valgus extension overload syndrome with olecranon osteophytes Olecranon stress fractures Osteochonritis dissicans (OCD) of the capitellum Loose bodies Sports Medicine

History Knowing the patient Knowing the sport Level of competition Chief complaint Pain While throwing At rest Decreased range of motion Clicking, locking, popping Instability Paresthesias Painless decreased velocity Change in accuracy Decreased stamina Sports Medicine

History Timing of symptoms Change in training Pitch counts Specific event When, how, date, finish Antecedent symptoms How many throwing trials since injury Timing Onset Frequency 85% have pain in late cocking and early acceleration phases Change in training Pitch counts Innings pitched Games pitched Rest between outings Other positions played when not pitching Sports Medicine

Physical Examination Inspection Athlete’s posture Arm position Fixed flexion, extension block from osteophytes posterior olecranon Muscle mass Scapular stability and function Skin Ecchymosis scars Carrying angle Elbow extended Full supination 11° in men 13° in women Asymmetries compared to contralateral side Sports Medicine

Palpation Imagine the anatomy under the skin Medial and lateral epicondyles, olecranon, radial head Be systematic, thorough and consistant Proximal to distal Bony, ligamentous, tendon, muscular, vascular, neuro Develop your way, stick with it Palpate in multiple positions or through a range of motion Palpate the radial head through flexion and supination/pronation Anterior bundle in extension and posterior bundle in full flexion Sports Medicine

Flexor Unit v. UCL The flexor/pronator mass/tendon lies just distal to the medial epicondyle at 90° Flex the wrist to accentuate tendon pain to differentiate UCL Flexing the elbow to 50° will bring the flexor mass anterioly to expose the UCL just posterior to the flexor mass Tenderness or swelling along the UCL can be identified Remember the anterior bundle attaches to the inferior portion of the medial epicondyle of the humerus and the medial edge of the coronoid process of the ulna Sports Medicine

Cubital Tunnel and Ulnar Nerve Just posterior to the medial epicondyle in the cubital tunnel Palpate the nerve From the arcade of Struthers to the FCU For tenderness or radicular pain Percussion (tinel sign) should be benign For radicular symptoms Flex and extend the elbow with and without pressure on the ulnar nerve just proximal to the medial epicondyle Feeling for anterior subluxation Causing radicular symptoms with palpation Sports Medicine

Laxity Supine or seated Humerus maximal external rotation Humerus flexed 30 Elbow flexed 30 To unlock the olecranon from the fossa Forearm maximally pronated Gentle valgus stress Less than 1mm of opening and a firm endpoint should be felt Compare to the contralateral side to estimate physiological laxity Increased pain or joint space opening in abnormal Sports Medicine

Milking Maneuver Tests the posterior band of the anterior bundle Forearm fully supinated Elbow at 120 Humerus adducted Thumb pulled laterally by the examiner or the contralateral hand Sports Medicine

Overload Test Seated position Forearm supinated Elbow slightly flexed One hand on the distal posterior humerus Other hand on the volar anterior forearm Rapidly extend the elbow with valgus stress Pain indicates impingement of the posterior medial tip of the olecranon on the medial wall of the fossa This happens when there is significant laxity of the UCL Sports Medicine

Xray Further workup modalities vary case to case Initial Evaluation Plain films AP, lateral, Oblique Pathology Calcifications of the UCL Osteophytes adjacent to the UCL Osteophytes of olecranon fossa Sclerotic OCD lesions Loose bodies Stress fractures 15% sensitivity Further workup modalities vary case to case Sports Medicine

Fluoroscopy Fluoroscopy Dynamic test To evaluate medial instability Pitchers may have some natural laxity >3 mm opening is concerning for UCL injury Sports Medicine

Three Phase Bone Scan For suspicion and detection of osseous injuries Can be positive as early at 2-8 days after onset of symptoms Stress injuries Sensitive but less specific Sports Medicine

MSK Ultrasound Rapid, noninvasive, nonradiating Contralateral comparison Inexpensive method for therapeutic guided injections Very useful in the elbow for Tendons Ligaments Muscles Bursa Neurovascular structures Dynamic testing of the UCL Able to apply valgus load while imaging. flexor mass medial epi UCL ulna Sports Medicine

MSK US Studies Sports Medicine Sasaki et al, 2002 DeSmet et al, 2002 30 Asymptomatic collegiate baseball players Only12 Pitchers Ulnohumeral joint space wider with more laxity at 90° DeSmet et al, 2002 Case report, 2 collegiate pitcher UCL injury, increased laxity, confirmed at surgery Nazarian et al, 2003 26 Asymptomatic professional pitchers Anterior band was thicker with more laxity Wood et al, 2010 Case report, collegiate pitcher UCL injury identified with US, negative MRI, visible tear with increased laxity on dynamic exam (milking), confirmed at surgery Ciccoti et al, 2014 368 Asymptomatic professional pitchers Preseason mechanical stress at 30° Thicker anterior band, more hypoechoic foci and calcifications, increased laxity Sports Medicine

CT Subtle fractures If the bone scan shows increased uptake CT can differentiate between stress fracture and other conditions Not sensitive enough for early stress fractures Sports Medicine

MRI Thorough test Multiple studies and UCL injuries Muscle, tendon, cartilage, bone, stress fracture changes, loose bodies, osteophytes and neurological changes Multiple studies and UCL injuries UCL Injuries 57% sensitivity 100% specificity MRI saline arthrogram May increase sensitivity to 92% Special Sequencing 86% sensitivity 91% specificity Sports Medicine

Severity Based Treatment Severity is based on the complete evaluation Grade 1 sprain Mild sprain Conservative plan Grade 2 sprain Partial tear Surgical repair for high demand athletes Grade 3 sprain Complete tear Surgical repair Sports Medicine

Non-Operative Treatment Week 0-2 Hinged elbow brace protected from full extension, full time Early therapy Week 3-6 Open all locks Prevent valgus stress Initial goal All clinical symptoms resolved no tenderness at UCL no pain with valgus stress When symptoms resolved Begin the pain free rehabilitation Full topic disussion later Brief overview in 3 slides Extend rest as needed for 8-12 weeks to achieve initial goal Sports Medicine

Platelet Rich Plasma Podesta, 2013 34 athletes with partial UCL tear Failed treatment at 2 months with pain or interval throwing failure Single ultrasound guided PRP injection 30/34 returned to pre-injury level 10-15 weeks (ave. 12 wks) Sports Medicine

Early Rehabilitation Start early Maintain ROM Cryotherapy Pain modulating electrotherapy Maintain ROM Elbow Shoulder Scapular based strengthening program Stated immediately for all UCL grade tears Core Lower extremity strengthening No gripping heavy weight or resistance Sports Medicine

Pain free Rehabilitation Full pain free ROM Progression Isometric to Isotonic Arm based to forearm based Focus on strengthening the medial dynamic stabilizers Pronator teres FCU Flexor digitorum superficialis Progress to a interval return to throwing program Sports Medicine

Interval Throwing Program Goal: at completion the athlete is prepared for the workload of competition at pre-injuy level of competition Position specific Age specific Level of play specific 45 minutes or less Many sources out there All programs start with shorter throws at 50% effort progress to longer tosses at ground level to build endurance and arm strength Pitching programs follow this starting with ground level to the mound and fastballs to off speed pitches Eventually to simulate games Sports Medicine

Surgery Defer to Dr. Scott Shemory Surgical options and repair of UCL tears Sports Medicine

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