1. Ulnar Collateral Ligament Injuries in Throwing Athletes
Nicholas Sablan, MD
Tidewater Orthopaedic Associates

2. Outline Biomechanics of Pitching Anatomy Exam Imaging
Nonsurgical Management
Surgical Management
Prevention

3. Biomechanics of Pitching
Every Pitch approaches maxium torque on UCL complex
Valgus forces at elbow (64Nm) can exceed the tensile strength of UCL (32Nm)
Fleisig, AJSM 1995
Fatigue of dynamic stabilizers

4. Anatomy Three parts Anterior Bundle Posterior Bundle
Transverse Ligament
Anterior bundle primary stabilizer to valgus stress from arc
Morrey, AJSM 1983
Feltner, IJSB 1987

5. Functional Anatomy
Humeral Origin lies posterior to axis of elbow flexion
Ligament tension varies with flexion
Distance between anterior bundle origin and insertion increases slightly from 0 to 60 degrees

6. History Medial elbow pain Early acceleration/late cocking phase
Chronic episodic with decreased accuracy/velocity/control most common
Sometimes acute “pop”
Ulnar nerve symptoms

7. Physical Examination
Tenderness
ROM
Flexor Pronator Mass
Ulnar Nerve

8. Stability Tests Valgus Stress test (Jobe) Milking Test (O’Brien)
Moving Valgus test

9. Imaging Plain Radiographs Stress Radiographs Ultrasound
MRI +/- Arthrogram

10. Plain Radiographs Arthritic Changes Bony Avulsions
Olecranon osteophytes
Calcifications

11. Stress Radiographs Average opening pitcher 0.32mm
>0.5mm diagnostic ?
Telos stress device

12. Ultrasound
Noninvasive
“Real” time
Injections
Stress testing

13. MRI
Assess Flexor Pronator origin
Sensitivity 57%
Specificity 100%

14. MRI: T SIGN Dye leak down the sublime tubercle
UCL attaches 2.8 mm from articular surface

15. Nonsurgical Management of PartialTears
No throwing minimum 6 weeks mild symptoms, 8-12 weeks moderate severity
Therapy focused on:
Pitching mechanics
Shoulder kinematics
Shoulder motion deficits
Core strength
Scapular stabilizers

16. Nonoperative management
Once pain free and kinetic chain deficits addressed
PRP injections?

17. Nonsurgical management Rettig et al, AJSM 2001
31 throwing athletes with UCL injuries
30 month f/u
Supervised rehab program
Phase I: rest 2-3 months, therapy
Phase II: throwing progression
41% return to level of play at average 24 weeks
No significant difference in duration, acuity of symptoms, or age of patient b/w those able to play/unable

18. Surgical Management Acute or chronic complete tear of UCL
Partial tears after “failure of conservative Rx” (Functional inability to throw secondary to medial elbow pain
Usually not necessary to operate on UCL injuries if athlete has no future in baseball or retiring (casual high school athlete?)

19. Goals of Surgical Treatment
Reconstruct UCL
Role for repair?
Treat Associated joint pathology
Ulnar nerve

20. Graft choices
Ipsilateral Palmaris
Contralateral gracilis
Allograft

21. Reconstruction of the UCL in Athletes Jobe, et al. JBJS, 1986
Reconstruction in 16 athletes
Lift off common flexor bundle
Routine Ulnar nerve transposition
68% return to previous play
High incidence of ulnar nerve complications

22. Muscle Splitting Approach to UCL Altchek et al AJSM 1996
Safe zone between braches of median and ulnar nerve
22 patients
No ulnar neuropathy

23. Modified UCL reconstruction
Muscle Splitting (protect MABC)
Selective ulnar nerve transposition
Fixation techniques?

24. UCL Reconstruction Outcomes ASMI Modified TJ
Muscle Splitting
Ulnar nerve transposition
82% return to play

25. Docking Technique Flexor mass divided Reduced # bone tunnels
Graft “docked” into medial epicondyle
90% return to play
Highest peak load to failure

26. Dane TJ Interference screw on ulna Docking technique on humerus
86% return to play

27. Postoperative Management
Splint for 1 week
ROM brace with therapy
Throwing program at 4 months
Return to competitive throwing 9-12 months

28. Complications
Ulnar Nerve
Fracture
Stiffness
Heterotopic ossification

29. Prevention Year Round Sport
Pitch Counts (USA baseball Medical Advisory Committee)
Curve Balls?

30. Thank You!