1. ULNAR COLLATERAL LIGAMENT OF THE ELBOW Jacob Kotlicky Program Coordinator Return to Sport – Memorial Hospital West

2. Articulations and Motions  Humeroulnar- Flexion & Extension  Humeroradial – Flexion/Extension, Pronation/Supination  Proximal Radioulnar – Pronation/Supination  Total ROM’s:Flex/Ext = 145˚-155˚ Pro/Sup = 170˚-180˚

3. Ligamentous Support  Ulnar Collateral Ligament - Primary medial stabilizer  Lateral Ulnar Collateral Ligament – Primary lateral stabilizer  Radial Collateral Ligament – supports against varus force, maintains humeroradial articulation  Annular Ligament – permits external/internal rotation of radius & ulna

4. UCL Breakdown  3 directional bundles  Anterior: Taut throughout full ROM, primary against valgus force  Posterior: Taught in flexion past 60˚  Transverse: Minimal support to medial elbow

5. Anatomy of the Elbow

6. Injury History/Observations  20 y/o baseball pitcher  junior classman w/ 0 spring innings played to date on collegiate level  Right hand dominant  No previous history of elbow injury  While throwing a curveball felt a “pop” and instant pain.  Threw two more pitches and felt his arm was “detached” as pain increased  Swelling over the medial aspect of R elbow

7. Palpations/Special Tests  No paresthesia, tinel’s sign, - fractures  Tenderness at UCL and medial epicondyle.  Pain with valgus stress w/ minimal gapping  AROM, PROM, RROM all WNL  Dermatomes/myotomes intact  Suspected UCL sprain.  Athlete prescribed naprosyn and went for immediate MRI

8. MRI Findings  UCL derangement of advanced stage and degree  “High-grade insertional partial tear involving the UCL insertion into the sublime tubercle”  “Thinning and attenuation of the distal inserting fibers”  Prominent edema in flexor pronator musculature  Chondromalacia and synovial thickening about the region.

9. UCL Reconstruction “Tommy John Surgery”  High rate of return to play  Tendon harvested. Typically palmaris longus. Hamstring tendon for this athlete  Tendon prepared – looped through holes drilled in radius and ulna at ligamentous attachment sites  Looped into a figure 8 and then sutured together.

11. Rehabilitation Process  Athlete immediately placed in a functional hinge brace  Extension initially limited to 60˚  Total amount of time braced will be 5-6 weeks  In-clinic 2 x week supplemented by HEP on daily basis  4 way SLR, heel drags and HS stretches  Shoulder isometrics

12. Rehabilitation Cont.  Began passive stretching of biceps on 11/17/08 – Athlete is hesitant with tightness and pain due to held flexion for nearly two weeks.

13. Return to Play Criteria  FULL ROM  Strength must be equal to that of other arm  No c/o pain in elbow w/ activity  Completion of shoulder program  Medical clearance from Dr. K.

14. References Koh, JL, Schafer, MF, Keuter, G, & Hsu, JE. Ulnar collateral ligament reconstruction in elite throwing athletes. Arthroscopy. 22 (11): 1187-1191 Safran, MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment. Clin Sports Med. 23 (4): 643-663 Chen FS, Rokito AS, & Jobe FW. Medial elbow problems in the overhead-throwing athlete. J Am Acad Orthop Surg. 9 (2): 99-113 Cain EL, & Dugas JR. History and examination of the thrower’s elbow. Clin Sports Med. 23 (3) 553-566 Limpisvasti O, ElAttrache NS, Jobe FW. Understanding shoulder and elbow injuries in baseball. J Am Acad Orthop Surg. 15 (3): 139-147 Hyman, J, Breazeale, NM, & Altchek, DW. Arthroscopic surgery for athletic elbow and wrist surgeries. Clin Sports Med. 20 (1): 5-21 Altcheck D, Hyman JL, Williams RJ. Ulnar collateral ligament reconstruction in throwers using the “docking” technique: two-year results. Sun Valley, ID, American Orthopaedic Association, 1999 Starkey C, Ryan J. Evaluation of Orthopedic and Athletic Injuries. 2 nd ed. Philadelphia, Pa: FA Davis Company; 2002

15. QUESTIONS? ??