Ulnar Collateral Ligament Rehabilitation By: Michael Cox

Bony Anatomy Humerous: Medial epicondyle- trochlea which serves as the axis of rotation for ulna on the humeorus Lateral epicondyle- capitellum which serves as the axis of rotation for the radius Radial fossa- accepts radial head during flx Coranoid fossa- accepts coranoid process during flx Olecronon fossa- accepts olecronon during ext Ulna: Olecronon process Coranoid process Radius: Radial head Radial tuberosity

Bony Anatomy Humeroulnar joint Hinge joint Strong and stable Allows for flexion and extension Humeroradial joint Modified ball and socket joint Proximal radioulnar joint Allows for pronation and supination

Ligamentous support Ulnar Collateral Ligament: Resists valgus loads 3 bundles Anterior- taut throughout full ROM, primary restraint against valgus stress Transverse- provides little medial support Posterior- taut in flexion beyond 60 degrees Lateral Collateral Ligament: Resists varus forces Composed of radial collateral ligament, lateral ulnar collateral ligament, annular and accessory ligament Annular Ligament: Encases radial head Doesn’t let ulna and radius move into flexion and extension independently

Musculature Flexors: Biceps brachii, brachioradialis, brachialis Extensors: Triceps brachii, anconeus Forearm Pronators: Pronator teres, pronator quadratus Forearm Supinators: Supinator, assisted by biceps and brachioradialis

Mechanism of Injury Most ulnar collateral ligament injuries occur in overhead throwing athletes This due to the extreme valgus stress placed on the elbow throughout the throwing motion Acutely the UCL can also be injured with a lateral blow to the elbow

Clinical Evaluation The patient will complain of pain on the medial aspect of the elbow that increases with motion Tingling or numbness may be present due to the tensile force placed on the ulnar nerve Point tender from the along the medial epicondyle Some swelling may be noticeable Positive valgus stress test

Acute treatment Refer patient for a MRI Restrict any throwing movements Can sling if more comfortable Modalities can be used to help reduce pain and inflammation such as ice and electrical stimulation for gate theory pain control

Surgical Patients If surgery Is needed- “Tommy John”- usually uses palmaris longus tendon as a graft to replace UCL Immobilization wit the arm at 90 degrees of flexion for 10-14 days At this time wrist and finger ROM exercises can be started Gripping exercises with puddy Shoulder ROM

Beginning Rehabilitation Weeks 0-3 Goals: Decrease pain and inflammation Improve ROM Retard atrophy

Early Rehab- Passive ROM Passive extension with dumbbell hanging off table (towel under joint) 2 lbs.for 5-7 minutes (long duration, low intensity stretch) Pulley flexion and extension 3 sets- 10 repetitions Clinician passive ROM

Early Rehab- Active ROM Wand exercises: 3 sets- 10 repetitions flexion extension pronation supination Wrist ROM Active ROM flexion, extension, pronation, supination

Early Rehab- Decreasing Pain Joint Mobilizations- grade I and II oscillations- posterior glide Ice Electrical Stim - gate theory

Early Rehab- Strengthening Isometrics flexion, extension, pronation, supination 3 sets of 10 repetitions holding contractions for about 5-10 seconds Refrain from internal and external rotation due to the valgus stress it places on the UCL

Intermediate Rehabilitation Weeks 4-8 Goals: Improving strength and endurance Reestablishing neuromuscular control Maintain full ROM Criteria: Near total ROM with minimal pain

Intermediate Rehabilitation Isotonic exercises Flexion extension pronation supination 3 sets- 10 repetitions Starting at 2lb dumbbell and progressing as strength increases Wrist isotonic exercises Rhythmic Stabilization clinician assisted swiss ball 4 sets- 20s

Intermediate Rehabilitation Diagonal PNF patterns Body Blade straight arm and at 90

Moderate Rehabilitation Weeks 9-13 Goals: Advanced strengthening phase Increase total arm strength, power, endurance, and neuromuscular control Prepare patient for functional return to play activities Criteria: Full non painful ROM Strength close to 70% of uninvolved limb

Moderate Rehabilitation Eccentric training Theraband- biceps and triceps

Moderate Rehabilitation Throwers 10- total arm strength Dumbbell abduction Prone dumbbell abduction Prone extension Internal rotation External rotation Theraband shoulder flexion and extension Progressive pushups Medicine ball punches- serratus anterior Diagonal D2 PNF Wrist flexion, extension, pronation, supination

Moderate Rehabilitation Plyometrics Med ball throws one hand Soccer throw Chest pass Side to side Plyometric press up

Moderate Rehabilitation Progressive medicine ball plyometrics Increased soccer throws 8-10 reps Side hits 2 sets- 30 seconds External rotation throws 3 sets- 10 reps

Final Rehabilitation Weeks 14-26 Goal: Progressive functional drills Continue to increase strength, endurance, power Return to play Criteria: Full ROM with no pain Full strength

Final Rehabilitation Throwing program Increase in distance and amount of throws Enough rest time in-between session: 2-3 days Batting practice Tees Soft toss Slow pitching Against a pitcher

Return To Play Full ROM Full strength No direct pain with throwing or hitting Normal cardiovascular endurance Physiologically ready

Article Emphasizes maintaining full elbow extension early Important to strengthen elbow and wrist flexors, and pronators- importance in follow through phase Rotator cuff strength Progressive and essential rehabilitation program

Summary Elbow joint has strong bony support as well as ligamentous and capsular support Mechanism of injury is usually repetitive valgus stress Progressive rehab with certain criteria that must be met before moving on Avoid internal and external rotation early in rehab due to valgus stress it places on elbow Maintain cardiovascular endurance and core strength throughout rehab Flexibility Continue strengthening once back to full participation to decrease risk of re-injury

Questions ??????????