Ulnar Collateral Ligament Injuries in Throwing Athletes Nicholas Sablan, MD Tidewater Orthopaedic Associates

Outline Biomechanics of Pitching Anatomy Exam Imaging Nonsurgical Management Surgical Management Prevention

Biomechanics of Pitching Every Pitch approaches maxium torque on UCL complex Valgus forces at elbow (64Nm) can exceed the tensile strength of UCL (32Nm) Fleisig, AJSM 1995 Fatigue of dynamic stabilizers

Anatomy Three parts Anterior Bundle Posterior Bundle Transverse Ligament Anterior bundle primary stabilizer to valgus stress from 30-120 arc Morrey, AJSM 1983 Feltner, IJSB 1987

Functional Anatomy Humeral Origin lies posterior to axis of elbow flexion Ligament tension varies with flexion Distance between anterior bundle origin and insertion increases slightly from 0 to 60 degrees

History Medial elbow pain Early acceleration/late cocking phase Chronic episodic with decreased accuracy/velocity/control most common Sometimes acute “pop” Ulnar nerve symptoms

Physical Examination Tenderness ROM Flexor Pronator Mass Ulnar Nerve

Stability Tests Valgus Stress test (Jobe) Milking Test (O’Brien) Moving Valgus test

Imaging Plain Radiographs Stress Radiographs Ultrasound MRI +/- Arthrogram

Plain Radiographs Arthritic Changes Bony Avulsions Olecranon osteophytes Calcifications

Stress Radiographs Average opening pitcher 0.32mm >0.5mm diagnostic ? Telos stress device

Ultrasound Noninvasive “Real” time Injections Stress testing

MRI Assess Flexor Pronator origin Sensitivity 57% Specificity 100%

MRI: T SIGN Dye leak down the sublime tubercle UCL attaches 2.8 mm from articular surface

Nonsurgical Management of PartialTears No throwing minimum 6 weeks mild symptoms, 8-12 weeks moderate severity Therapy focused on: Pitching mechanics Shoulder kinematics Shoulder motion deficits Core strength Scapular stabilizers

Nonoperative management Once pain free and kinetic chain deficits addressed PRP injections?

Nonsurgical management Rettig et al, AJSM 2001 31 throwing athletes with UCL injuries 30 month f/u Supervised rehab program Phase I: rest 2-3 months, therapy Phase II: throwing progression 41% return to level of play at average 24 weeks No significant difference in duration, acuity of symptoms, or age of patient b/w those able to play/unable

Surgical Management Acute or chronic complete tear of UCL Partial tears after “failure of conservative Rx” (Functional inability to throw secondary to medial elbow pain Usually not necessary to operate on UCL injuries if athlete has no future in baseball or retiring (casual high school athlete?)

Goals of Surgical Treatment Reconstruct UCL Role for repair? Treat Associated joint pathology Ulnar nerve

Graft choices Ipsilateral Palmaris Contralateral gracilis Allograft

Reconstruction of the UCL in Athletes Jobe, et al. JBJS, 1986 Reconstruction in 16 athletes Lift off common flexor bundle Routine Ulnar nerve transposition 68% return to previous play High incidence of ulnar nerve complications

Muscle Splitting Approach to UCL Altchek et al AJSM 1996 Safe zone between braches of median and ulnar nerve 22 patients No ulnar neuropathy

Modified UCL reconstruction Muscle Splitting (protect MABC) Selective ulnar nerve transposition Fixation techniques?

UCL Reconstruction Outcomes ASMI Modified TJ Muscle Splitting Ulnar nerve transposition 82% return to play

Docking Technique Flexor mass divided Reduced # bone tunnels Graft “docked” into medial epicondyle 90% return to play Highest peak load to failure

Dane TJ Interference screw on ulna Docking technique on humerus 86% return to play

Postoperative Management Splint for 1 week ROM brace with therapy Throwing program at 4 months Return to competitive throwing 9-12 months

Complications Ulnar Nerve Fracture Stiffness Heterotopic ossification

Prevention Year Round Sport Pitch Counts (USA baseball Medical Advisory Committee) Curve Balls?

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