REVIEW ARTICLE

Ulnar Collateral Ligament in the Overhead Athlete: A Current Review Jeffrey Dugas, MD, Justin Chronister, MD, E. Lyle Cain, Jr, MD, and James R. Andrews, MD

Abstract: Ulnar collateral ligament (UCL) injuries are most commonly reported in baseball players (particularly in pitchers) but have also been observed in other overhead athletes including javelin, softball, tennis, volleyball, water polo, and gymnastics. Partial injuries have been successfully treated with appropriate nonoperative measures but complete tears and chronic injuries have shown less benefit from conservative measures. In these cases, surgical reconstruction has become the treatment modality for overhead athlete who wishes to continue to play. This article discusses the functional anatomy and biomechanics of the UCL as related to the pathophysiology of overhead throwing, as well as the important clinical methods needed to make accurate and timely diagnosis. It also gives an updated review of the current clinical outcomes and complications of surgical reconstruction. Key Words: elbow ulnar collateral ligament, elbow instability, overhead throwing athlete, pitcher, Tommy John surgery

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T

ears of the ulnar collateral ligament (UCL) of the elbow may cause medial elbow pain and instability. The first description of elbow problems in overhead athletes was published in 1941, when Bennett1 documented elbow and shoulder injuries in professional baseball players. Five years later, Waris2 specifically described UCL injuries in javelin throwers. Since that time UCL injuries have been reported in many overhead athletes including javelin, water polo, gymnastics, wrestling, football (usually the quarterback), tennis, golf, and, most commonly, in baseball players (especially pitchers).3–7 In the early 1970s, King investigated a group of pitchers and found a 50% annual incidence of shoulder and elbow injuries.8,9 He also reported his theory on the etiology of medial elbow pathology in professional baseball pitchers called “medial stress syndrome.” He believed that extreme recurrent valgus stress in overhead throwing, particularly during the late cocking and early acceleration phase of pitching, is transmitted to the medial elbow, leading to progressive failure of structures including the elbow musculature, UCL, capsule, and then the joint itself. Subsequent research revealed the anterior bundle of the UCL complex to be the primary restraint to valgus forces of the elbow and that this structure either fails acutely or by chronic microtrauma.5,10–15 Failure of the UCL in the overhead athlete can lead to pain, instability, decreased performance, and/or inability to participate.16–21 From the Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL. Disclosure: The authors declare no conflict of interest. Reprints: Jeffrey Dugas, MD, American Sports Medicine Institute, 805 St. Vincent’s Dr. Suite 100, Birmingham, AL 35205. Copyright r 2014 by Lippincott Williams & Wilkins

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Early recognition, treatment, and rehabilitation are all necessary to ensure the best chance for the athlete to return to preinjury levels of participation without prolonged delay. This article reviews the functional anatomy and biomechanics of the UCL, pathophysiology of the thrower’s elbow and its history, physical examination, imaging modalities, and treatment options. It will also give an updated review of clinical outcomes and complications of surgical reconstruction.

ANATOMY The elbow joint is a hinge joint and its stable motion is dependent on osseous, capsular, muscular, and ligamentous components for primary and secondary support. Bony anatomy provides primary stability at 120 degrees of flexion. Soft tissue restraints provide primary static and dynamic stability from 20 to 120 degrees of flexion, the arc of motion where overhead throwing occurs.12–15,22 The UCL complex is composed of 3 bundles: the anterior oblique ligament (AOL), the posterior oblique ligament (POL), and the transverse ligament. The AOL originates on the anterior and inferior aspect of the medial epicondyle (mean footprint 46 mm2) and inserts approximately 5 mm distal to the ulnohumeral joint onto the sublime tubercle of the ulna (mean footprint 128 mm2), with a long tapered insertion running down the medial ulna23,24 (Figs. 1A, B). The mean length of the AOL is 27 mm and the mean width is 5 to 8 mm.13,25,26 It is the strongest elbow collateral ligament with an average failure load of 260 N.15 Of the 3 ligaments making up the UCL complex, only the anterior bundle provides significant restraint to valgus force of the elbow from 30 to 120 degrees. The AOL itself has 3 functional bands: anterior, central, and posterior. The anterior and posterior bands work in a reciprocal function in resisting valgus stress through the range of motion.12,13,15 The anterior band is taut through the first 90 degrees at which point the posterior band becomes taut with further flexion through 120 degrees.27 The concept of isometric fibers continues to be debated. Previous studies have refuted the idea,12,13,28 whereas more recent studies give support, one by Ochi and colleagues describes the deep central band as isometric and having an origin at the trochlear center of rotation.29,30 The POL is a fan-like thickening of the capsule with an origin posterior to the AOL on the medial epicondyle and insertion on the medial ulna’s sigmoid notch. It serves as a secondary restraint to valgus loading. The transverse ligament spans between the AOL and POL insertions. It is generally believed to not contribute to elbow stability.13,26 The transverse ligament spans the insertion of the AOL and POL along the medial ulna, extending from the

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FIGURE 1. A, Origin of the anterior bundle dissected from its osseous attachment on the medial humeral epicondyle. B, Insertion of the anterior bundle dissected from its osseous attachment on the sublime tubercle of the ulna. Reprinted from Dugas JR, Ostrander RV, Cain EL, et al. Anatomy of the anterior bundle of the ulnar collateral ligament. J Shoulder Elbow Surg. 2007;16:657–660. http:// www.sciencedirect.com/science/article/pii/S1058274607002352.

inferior medial coronoid process to the medial tip of the olecranon.31,32

BIOMECHANICS The elbow is subject to extreme valgus stresses during throwing. These stresses are greatest during late cocking and early acceleration phases of throwing, when the humerus is externally rotated, the elbow is flexed, and a moment is created by the ball in the hand. The elbow serves as a fulcrum over which the moment of the ball in hand and the rotational forces of the trunk act.3,27,33–35 Biomechanical studies have estimated that during throwing the medial shear forces exceed 300 N, lateral compressive forces exceed 900 N, and elbow extends at 2500 degrees per second.34–37 Valgus stress applied to the elbow during the late cocking and early acceleration phase is 64 N m.36 In cadaveric specimens the UCL has been shown to only withstand 33 N m (approximately 54% of 64 N m).34 Therefore, other contributions from bony anatomy, medial structures, and dynamic stabilizers also play a role. In pitching, maximum velocity has been shown to be significantly associated with risk of elbow injury in professional athletes. In one study the 3 individuals with the highest velocities all had injury requiring surgical reconstruction.38 Throwing a fastball generates the greatest mean valgus torque at the medial elbow (compared with curveball, change up, and slider).39,40 In youth pitchers, Dun and colleagues also showed that the fastball generates the greatest valgus torque, whereas others found that pitch count during a game and cumulative count over a season are significantly associated with elbow injury.41–43 Repetitive, near failure loads applied during throwing may result in microtrauma to the anterior bundle of the UCL and may eventually lead to ligament attenuation or failure. The forces at the elbow caused by repetitive valgus stress result in: (1) traction/tensile forces on their medial structures (ie, the UCL, ulnar nerve, flexor-pronator mass), (2) compression forces on their lateral structures (ie, the radiocapitellar joint), and (3) compression/impingement and shear forces in their posteromedial compartment). There are several other pathologies associated with UCL insufficiency. Excessive medial soft tissue stretch may lead to flexor tendonitis or medial epicondylitis. The flexorpronator mass is the primary dynamic stabilizer to valgus stress, with the flexor carpi ulnaris and the flexor digitorum superficialis being the most important.44,45 With repetitive overhead throwing, these muscles may experience fatigue or injury. Studies have shown dysfunction of the flexor-pronator group with known UCL insufficiency.46 Others have

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reported concomitant tearing of flexor-pronator tendon in patients having UCL operations.4,7 Increased valgus instability and traction on the medial elbow may cause traction neuritis on the ulnar nerve,47,48 as well as marginal osteophytes at the medial joint. Posteromedial olecranon osteophytes may develop because of shear and compressive forces between the olecranon tip and the olecranon fossa. This phenomenon has been termed as “valgus extension overload syndrome.”49 Osteophytes in these compartments may detach and form loose bodies.34,50 Valgus torque also leads to compressive forces in the lateral elbow between the capitellum and the radial head. This potentially leads to avascular necrosis, osteochondritis dissecans, chondral wear, and degenerative changes.34,51 Young athletes with open physes and additional flexibility are at increased risk of osteochondritis dissecans of the capitellum because of increased loads borne on the radiocapitellar joint. “Little league elbow” is seen in immature throwers and is a general term including medial epicondylar avulsion, apophysitis, or accelerated apophyseal growth due to medial tensile forces.52,53 Thus, the age of the individual is an important variable to be considered when evaluating throwing athletes with elbow pain.

HISTORY Medial elbow complaints are common in overhead athletes at all levels of competition. A history must include the athlete’s age, sport, level of participation, position, hand dominance, and sports participation calendar (in and out of season). Details regarding the onset, chronicity, changes in training regimens, activities causing pain, as well as prior injuries may help the physician better understand the patient’s current condition. Specifically for throwing athletes, any changes in accuracy, velocity, stamina, and strength are necessary. Equally as important are the style of throwing mechanics and the phase of throwing during which pain is experienced.34,54 In athletes with medial elbow instability, nearly 85% will experience pain during the late cocking and early acceleration phase, whereas 1 mm is abnormal. Callaway and colleagues showed opening is very minimal, whereas Thompson and colleagues documented that only half of patients reported pain.28,64 Overall, this maneuver is 66% sensitive and 60% specific for detecting abnormalities of the anterior bundle.61 The modified milking maneuver (Fig. 2) utilizes the laxity found at 70 degrees of flexion with UCL insufficiency.66 The www.sportsmedarthro.com |

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maneuver has been reported to be 100% sensitive and 75% specific using arthroscopic valgus stress testing and surgical exploration as the gold standard.

IMAGING

FIGURE 2. Modified milking maneuver. Described by Safran.65

shoulder is adducted and maximally externally rotated. The examiner uses one hand to place the elbow at 70 degrees and holds external rotation (valgus force at the elbow), whereas the other hand holds the elbow adducted and feels for medial joint space opening and end point. The moving valgus stress test (Figs. 3A, B) attempts to replicate the dynamic torque that the UCL must resist during a throw.67 To perform this examination the patient’s shoulder is held at 90 degrees of abduction and is externally rotated. The examiner then moves the elbow from full flexion to extension while maintaining a constant valgus stress on the elbow. A positive test will elicit pain between 120 to 70 degrees, which is the functional range during throwing. This

Several imaging modalities can aid in the diagnosis and treatment of UCL injury. Plain radiographs may reveal avulsion fragments in the acute injury, as well as loose bodies, calcifications, ossifications, subchondral sclerosis, joint space narrowing, and osteophytes of the radiocapitellar joint and/or posteriomedial compartment. A standard throwers x-ray series includes anteroposterior (AP), lateral, internal/external oblique views, and an oblique axial view with the elbow in 110 degrees of flexion to demonstrate posteromedial olecranon osteophytes.59 The effects of traction on the medial elbow are best visualized on the AP view. One study found a 44% prevalence of UCL ossification and traction spurs in professional baseball players,8 whereas another study found that in a population of patients undergoing surgery for UCL insufficiency, 76% had heterotrophic calcification of the ligament evident on plain radiographs.68 The AP and lateral views are utilized to visualize loose bodies, joint line abnormalities, and osteophytes. Osteophytes are also seen on the posteromedial olecranon as part of valgus extension overload and are best visualized with the 110-degree flexion oblique axial view. If medial instability is suspected, stress AP radiographs can be performed manually or with the use of a valgus stress radiography machine. Stress views of the injured and uninjured elbows in 25 to 30 degrees of flexion are obtained while holding a valgus force. Rijke and colleagues investigated stress radiograph in athletes and found that a side to side difference of >0.5 mm medial joint opening indicated a significant partial or complete UCL tear. Athletes with widening of 80% of cases.105,113 When the palmaris is not available the gracilis hamstring tendon is a common autograft that is used. Larger alternative grafts are also used in the case of tissue loss, which is common in chronic UCL insufficiency when intraligamentous bone is identified. Dugas et al101 reported a retrospective cohort study in which contralateral gracilis autograft was used on athletes for UCL reconstruction. Among the 120 patients, 42 (35%) had bone within, or replacing, the substance of the native UCL, and 78 (65%) had no bony abnormalities. They found no statistical differences regarding time to return to throwing, time to competition, number of complications, or need for additional surgery. Two players in the bony abnormality group did require revision UCL surgery. There was also a trend toward decrease rate of return to preinjury level in the bony group but was not statistically significant. The only significant difference was a self-reported decrease in pitch control in the bony group. It is the conclusion of this author that hamstring autograft is a good option for UCL reconstruction but the loss of native tissue may have significant effects on postoperative pitch control. More recently, because of the increase of cadaver soft tissue availability and safety, allograft tissue use is becoming more common. This can be attributed to decreased surgical time and decreased morbidity. Graft incorporation and elongation is a concern with allograft tissue. The use of allograft hamstring for anterior cruciate ligament reconstruction has shown higher postoperative instability rates when compared with autograft. Only one recent clinical study reports the outcome of allograft utilization for UCL reconstruction. Savoie et al5 performed a retrospective study on 116 overhead athletes who underwent UCL reconstruction with hamstring allograft and were followed for a minimum of 24 months.100 He showed that 88% returned to their previous level of play or higher at an average of 9.5 months. There were 3 postoperative ulnar nerve complications, one requiring neurolysis, and no UCL revision reconstructions were required. Overall, in this study the use of hamstring allograft seems to be a viable option with similar result and return time as previous studies using autograft.

Revision UCL Reconstruction The literature shows that excellent results can be expected in patients who undergo primary UCL reconstruction. The literature has not been as extensive in evaluating revision UCL reconstruction. Dines et al114 provided r

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the first clinical report on revision UCL reconstruction outcomes in a series of 15 baseball players. Only 33% were able to return to their preinjury level of play and the complication rate was reported at 40%. A more recent study by Jones et al102 reports the functional outcomes of 18 MLB pitchers. Seventy-eight percent (14/18) were able to return to MLB play but the rate of return to preinjury pitching workload was low. Relief pitchers were able to resume an average of 50% of their preinjury pitch workload, whereas starters could only resume 35% of their prior workload. This suggests that starting pitchers may be predisposed to poorer outcomes and may benefit from reassignment to a reliever role. Overall, the rate of UCL reconstruction is climbing drastically in the recent years, particularly in young athletes.96 Therefore, we may see an increase in the rate of revisions in the future as well. Further clinical follow-up data are needed to elucidate the outcome in patient athletes after revision UCL reconstruction.

REHABILITATION A standard postoperative rehabilitation protocol should be used in all cases. The senior author of this paper uses a 4-phase protocol described by Wilk and colleagues.115–117 The first phase begins immediately after surgery and continues for 3 weeks. The elbow is placed in a compression dressing and a posterior splint at 90 degrees for 1 week. The next week physical therapy is begun for swelling management and to restore full range of motion by the fifth or sixth week. During phase 2 (weeks 4 to 10), a progressive isotonic strengthening program is initiated. Exercises focus on the scapula, shoulder, and arm musculature. Shoulder range of motion and stretching are performed in this phase and the Thrower’s 10 Exercise Program is initiated. Phase 3 (weeks 10 to 16) is the advanced strengthening stage. During this stage, flexibility, core, isotonic exercises, and sport-specific exercise movements are progressed. At 12 weeks throwers start a 2-handed plyometric throwing program and at 14 weeks a 1-handed plyo program. At the end of phase 3 and throughout phase 4 (weeks 16 and beyond) an interval throwing program and a hitting program are begun until the patient is able to return to their appropriate position.

DISCUSSION AND OUTLOOK The UCL is the primary restraint to elbow valgus instability. Overhead throwing athletes place substantial demands on the medial elbow and may experience acute ruptures of the UCL or may have chronic progressive attenuation of the UCL. Most elbow symptoms result from overuse or are secondary to disturbances in the throwing kinetic chain. A clinician must have a multimodal approach to quickly and accurately diagnose elbow pain and injury in the overhead athlete. History, physical examination, and x-ray are essential to diagnosis but MRI arthrography has been found to be very sensitive and specific for all types of UCL injury and can be helpful in directing treatment. MR arthrography is now the gold standard diagnostic test for medial elbow pain in the athlete. Primary repair is considered in young athletes and in the case of acute avulsion injury, but reconstruction using free tendon graft is now the standard of care for the majority of UCL ruptures in overhead athletes. The literature shows that with advancement of UCL reconstruction techniques, including minimal dissection of the flexor-pronator mass and abandonment of www.sportsmedarthro.com |

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submuscular ulnar nerve transposition, overhead athletes who undergo UCL reconstruction may successfully return to their preinjury levels without significant complication.

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2014 Lippincott Williams & Wilkins

Ulnar collateral ligament in the overhead athlete: a current review.

Ulnar collateral ligament (UCL) injuries are most commonly reported in baseball players (particularly in pitchers) but have also been observed in othe...
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