1. Sports Medicine Approach to Ulnar Collateral Ligament Injuries
Bob Crawford, MD CAQSM
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

2. 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
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3. 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

4. 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
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5. 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
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6. 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
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7. 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
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8. 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
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9. 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

10. 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
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11. 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
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12. 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
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13. 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
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14. Fluoroscopy Fluoroscopy Dynamic test To evaluate medial instability
Pitchers may have some natural laxity
>3 mm opening is concerning for UCL injury
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15. 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
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16. 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

17. 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
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18. 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
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19. 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
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20. 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
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21. 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

22. 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 weeks (ave. 12 wks)
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23. 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
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24. 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
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25. 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
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26. Surgery Defer to Dr. Scott Shemory
Surgical options and repair of UCL tears
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27. Bibliography Sports Medicine
Patel, Lynch, Amin, Calabrese, Gryzlo, Schickendantz. The Thrower’s Elbow. Orthopedic Clinics North America 2014; (45):
Leahy, Schorpion, Ganley. Common Medial Elbow Injuries in the Adolescent Athlete. Journal of Hand Therapy 2015; (28):
Schickendantz. Diagnosis and Treatment of Elbow Disorders in the Overhead Athlete. Hand Clinics 2002; (18):
Redler, Dines. Elbow Trauma in the Athlete. Hand Clinics 2015; (31):
Ciccotti, Atanda, Nazarian, Dodson, Holmes, Cohen. Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers. American Journal Sports Medicine 2014; 42(3):
Wood, Konin, Nofsinger. Diagnosis of an Ulnar Collateral Ligament Tear using Musculoskeletal Ultrasound in a Collegiate Baseball Picher: A Case Report. North American Journal of Sports Physical Therapy 2010; 5(4):
Hibberd, Brown, Hoffer. Optimal Management of Ulnar Collateral Ligament Injury in Baseball Pitchers. Open Access Journal of Sports Medicine 2015; (6):
Rettig, Sherrill, Snead, Mendler, Mieling. Nonoperative Treatment of Ulnar Collateral Ligament Injuries in Throwing Athletes. American Journal of Sports Medicine 2001; 29(1):
Podesta, Crow, Volkmer. Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow with Platelet Rich Plasma. American Journal Sports Medicine 2013; 41(7):
Yocum. The Diagnosis and Nonoperative Treatment of Elbow Problems in the Athlete. Clinics in Sports Medicine 1989; 8(3):
Axe, Hurd, Snyder-Mackler. Data-Based Interval Throwing Programs for Baseball Players. Sports Health 2009; 1(2):
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