1. Rehab and Prevention of Ulnar Collateral Ligament Injuries Lucas C. Smith PT, DPT, CSCS

2. Anatomy of the Ulnar Collateral Ligament (UCL) UCL, Also known as the medial collateral ligament is composed of 3 bundles. Anterior Bundle (most commonly injured) Posterior Bundle Transverse Ligament The UCL connects the Humerus to the Ulna, and prevents elbow valgus and distraction. 2

3. Mechanism of Injury to the UCL Most common is repetitive valgus force at the elbow. Common in overhead sports –Baseball –Volleyball The average valgus stress at the elbow for an adult pitcher is 64 N.m. The UCL provides 54% of resistance to this stress therefore 34 N.m per pitch! Acute trauma providing a strong valgus stress to the elbow. 3

4. Common Signs and Symptoms Pain when using your arm in an overhead position. 85% of cases will report pain with the acceleration phase of throwing. If injury is acute reports of hearing a “pop”. Pitchers may report decreased accuracy, velocity, control, stamina, and strength. Reports of soreness and swelling along the medial elbow. Possible numbness and tingling in the forearm. Instability of the elbow “It feels like my elbow is going to give out when I throw”. 4

5. Physical Therapy Evaluation Start with a detailed history Is the injury Acute or Chronic? Did you have have surgery? What sport or activity contributed to the issues? How long have you had the pain? Did you hear a pop? Do you have any numbness or tingling? How long have you been playing your sport, and how often do you play? Are you currently playing? 5

6. Physical Therapy Evaluation Palpate along the medial elbow and look for areas of pain. Apply pressure to the UCL, Ulnar nerve, and Common flexor tendon. Assess ROM of the elbow and shoulder Recent studies have shown that a decrease in Total Shoulder ROM is associated with UCL injuries in baseball players. Professional baseball pitchers have been shown to lack 3-5 degrees of elbow extension at baseline. If post op follow the ROM restrictions at the elbow per protocol. 6

7. Physical Therapy Evaluation If Patient has not had surgery perform manual muscle tests (MMT). Wrist, Elbow, Shoulder, Scap/upper back, Core Remember to Include the Pronator Teres and wrist flexors primarily the Flexor Carpi Ulnaris because they are the primary protectors of the UCL. Test balance with single leg stance or Y balance test. Poor mechanics and movement patterns due to decreased balance and core strength can cause increased risk for injury. 7

8. Physical Therapy Evaluation If non operative perform Special Tests. Valgus stress test Have the patient sit with their elbow flexed at 20-30 degrees and provide a valgus force to the elbow. –A positive test will be pain and/or laxity. Moving Valgus stress test Have the patient sit with their shoulder in the 90/90 position. Apply and maintain a constant moderate valgus torque to the fully flexed elbow and then quickly extends the elbow. A positive test is medial elbow pain reproduced between 120 degrees and 70 degrees. 8

9. Non Operative Rehab for the UCL Pain and Inflammation Reduction. Soft tissue mobility to break up scar tissue, remove fluid build up and increase tissue extensibility. Deep Tissue Massage Cross Friction Massage Graston Use of modalities to control inflammation and pain. If acute use Cryotherapy and Electrical Stimulation. If chronic Heat and Ultrasound. 9

10. Non Operative Rehab for the UCL Improve and Maintain ROM Perform ROM in all planes of the elbow and wrist. The main goal of ROM activities prevent and eliminate any elbow flexion contractures. Perform active assistive and passive ROM to the elbow and wrist. Also utilize joint mobility performing posterior glides of both the Humeroulnar joint to help with elbow extension, and the Glenohumeral joint to help with shoulder rotation mobility. 10

11. Non Operative Rehab for the UCL Improve and Maintain ROM If the patient has an extension contracture use a low-load long- duration stretch. Lay the patient supine on a table with their arm out stretched with a towel under the upper arm. The shoulder should be internally rotated with the forearm pronated. –Apply light resistance with a band or weight. Pt should hold the stretch for 10-15 min 11

12. Non Operative Rehab for the UCL Early Strengthening activities When patient has achieved full ROM and minimal pain and tenderness start isotonic strengthening exercise. Elbow and wrist Flexion/Extension, Forearm Pronation/Supination. Start with basic exercises with a t-band or dumbbell. Glenohumeral and Scapulothoracic strengthening Focus on shoulder ER and periscapular musculature. Exercise can be performed with t-band or dumbbells Great exercises at this point are the throwers 10 exercises Core strengthening and stability. 12

13. Throwers 10 Exercise 13

14. Non Operative Rehab for the UCL As strength improves start advanced strengthening activities. Increase Resistance Rhythmic stabilization exercise Change speeds with exercise Plyometric exercise High Level balance activities To begin these exercises the patient should have full non painful ROM, no pain or tenderness with palpation, and strength of effected arm should be 70% of contralateral arm. 14

15. Non Operative Rehab for the UCL Increase Resistance Start to incorporate exercise in the gym with free weights and machines. Start with chest press, seated rows, lat pull downs, and triceps extension Start increased resistance biceps muscle eccentric exercise. This is important because the biceps is a very important stabilizer in the follow through phase of throwing. 15

16. Non Operative Rehab for the UCL Rhythmic stabilization exercise Start with supine rhythmic stabilization exercise with arm at 90 deg flex, and then incorporate PNF patterns. Add manual resistance with exercise and rhythmic stabilizations at end range. This can be done with any of the throwers 10 exercises. Closed Chain rhythmic stabilization. Ball on wall exercise. Prone with hands on ball and perform rhythmic stabilizations. 16

17. Non Operative Rehab for the UCL Change Speed with Exercise Perform with a t-band of varying resistance. Seated and or standing wrist flexion and extension alternating reps of fast and slow sets. Perform the same technique with elbow flex and extension, shoulder IR and ER, and shoulder extension. Start to incorporate sustained holds with exercise. Hold for 5-10 seconds at the end of the concentric contraction. 17

18. Non Operative Rehab for the UCL Plyometric Exercise Start in a push up/plank position and perform UE step ups, progressing to UE jump ups. Forward, lateral, in, and diagonal patterns Plyometrics are also performed with a medicine ball. Start with 2 handed activities. –Chest pass, side to side throw, and overhead soccer throws. 18

19. Non Operative Rehab for the UCL Progress 2 handed plyometrics to 1 handed with medicine ball Perform wrist flexion and extension flips. Shoulder internal and external rotation throws. Perform at 0 degrees and 90 degrees. Prone shoulder 90/90 external rotation throws. Eccentric shoulder ER catching with a concentric return. Both great for posterior rotator cuff strengthening. Overhead wall dribbles for endurance. 19

20. Non Operative Rehab for the UCL High Level Balance Activities This is where you simply get creative. Perform many of the previous exercise on one leg or on a stability ball. –All IR and ER exercise including plyometrics on one leg. Progress to unstable surface. –Throwers 10 exercises sitting or laying on a swiss ball. –Chest and overhead passes from a BOSU 20

21. Non Operative Rehab for the UCL Return to activity and sport When the patient has full strength, ROM, and is pain free start a progressive return to activity program. For example a interval throwing program. Return to golf program. When the patient has finished the interval program pain free, has no pain or tenderness, passes all isokinetic testing they should return to the MD for a release back to full activity. 21

22. Post Operative Rehab for the UCL Always follow the surgeons protocol if they have one and if they do not, get approval of the protocol you wish to use before proceeding. In my experience the UCL reconstructions I have seen are those using the autogenous palmaris longus graft. I prefer to use the Andrews Protocol developed by Dr. Andrews. All protocols including the Andrews protocol will incorporate the same ROM activities and exercise described in the non operative sections they are just introduced at different times and ROM progresses differently. 22

23. Prevention of UCL Injuries The first line of prevention of UCL injuries is education. Research has shown that the amount of pitching is directly linked to UCL injuries Therefore we need to educate patients and coaches on the importance of limiting pitch counts, varying speeds of pitches, and avoid playing year round. A great line from the American Sports Medicine Institute (ASMI) “To become a successful adult pitcher, the youth should not strive to be a “youth pitcher” but instead a young athlete that is a good pitcher.” 23

24. Prevention of UCL Injuries Maintain good shoulder ROM Decreased total shoulder ROM has been directly linked to UCL injuries therefore it is important to regularly stretch the shoulder musculature and capsule. Maintain strong scapular musculature and condition all of the muscle in the kinetic chain of throwing. Work from the ground up. Make the throwers 10 exercise part of you normal routine. –Both traditional and with balance modifications. CORE strength is key to stability and throwing mechanics therefore don’t forget. Include the primary muscles that protect the UCL, the Pronator Teres and Flexor Carpi Ulnaris. Full body conditioning with cross training. 24

25. Prevention of UCL Injuries Rest and Proper Nutrition Vital to all athletes and often forgotten is the importance of rest and proper nutrition. Both are required to allow the body to recover and rebuild after activity and necessary to obtain peek performance. 25

26. THANK YOU 26

27. References O’Driscoll SW, Lawton RL, Smith AM. (2005). The “moving valgus stress test” for medial collateral ligament tears of the elbow. American Journal of Sports Medicine. 33(2): 231-9 American Sports Medicine Institute. (2014). Position Statement for Tommy Jon Injuries in Baseball Pitchers. Retrieved from http://www.asmi.org/research.php?page=research &section =Tjpositionstatement Garrison JC, Cole MA, Conway JE, Macko MJ, Thigpen C, Shanley E. (2012). Shoulder range of motion deficits in baseball players with ulnar collateral ligament tear. American Journal of Sports Medicine. 40(11) 2597-603 Houston Methodist Leading Medicine. (2016). A PATIENT'S GUIDE TO ULNAR COLLATERAL LIGAMENT INJURIES Retrieved from http://www.houstonmethodist.org/orthopedics/where-does-it-hurt/elbow/ulnar-collateral-ligament-injuries/ Wilk KE, Macrina LC, Cain EL, Douglas JR, Andrews JR. (2012) Rehabilitation of the Overhead Athletes Elbow. Sports Health 4(5) 404-14 Ellenbecker TS, Wilks KE, Altchek DW, Andrewes JR. (2009). Current Concepts in Rehabilitation Following Ulnar Collateral Ligament Reconstruction. Sports Health. 1(4) 301-313 Langer P, Fadale P, Hulstyn M. (2006). Evolution of the Treatment Options of Ulnar Collateral Ligament Injuries of the Elbow. Brittish Journal of Sports Medicine. 40(6) 499-506 Garrison CJ, Arnold A, Macko MJ, Conway JE. (2013). Baseball Players Diagnosed with Ulnar Collateral Ligament Tears Demonstrate Decreased Balance Compared to Healthy Controls. Journal of Orthopaedic & Sports Physical Therapy. 43(10) 752-758 Garrison C, Hannon J. (2016). Physical Therapist Guide to Ulnar Collateral Ligament Injury. Move Forward. Retrieved from http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=ddbd540d-6f4c-4417-9195-14f42aa9dd41 27