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Ulnar Collateral Ligament Injuries of the Elbow

Abstract

Purpose of Review

This review discusses the current practice of evaluation and treatment of injuries to the ulnar collateral ligament (UCL) of the elbow with emphasis on rehabilitation.

Recent Findings

The latest studies revolve primarily around surgical repair and regenerative medicine for the UCL. Conservative management remains the mainstay of treatment, but surgical intervention may be advantageous in the appropriate patient.

Summary

Elbow ulnar collateral ligament injuries have increased throughout the twentieth century, primarily in overhead athletes. Specifically, baseball pitchers are at high risk due to repetitive valgus elbow strain while throwing baseballs at a high velocity. Current epidemiology, anatomy, diagnosis (physical exam, imaging), and treatment (injections, surgery, and rehabilitation) of UCL injury are discussed.

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Fig. 1

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Correspondence to Keith Cummings.

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Appendix

Appendix

The Thrower’s Ten Program (Description)

Exercises 1 and 2 utilize resistance tubing to perform diagonal extension and flexion along with external and internal rotation at both 0° and 90° abductions. The athlete performs shoulder abduction to 90° for exercise 3. Exercises 4 and 5 focus on external rotation (scaption and sidelying, respectively). The athlete is prone for exercise 6, performing horizontal abduction (neutral with palm down and with thumb rotated up), rowing, and rowing with external rotation to 90°. Exercise 7 involves press-ups while seated on a chair while exercise 8 utilizes push-ups with shoulders rolled forward once the elbows are straightened. Push-ups progress from performing into a wall, to a table top, and finally to the floor as strength grows. Exercise 9 strengthens elbow and wrist flexion and extension. The elbow is flexed against resistance and extended with the shoulder abducted, while the wrist is flexed and extended with the forearm supported. The same forearm position is maintained for exercise 10 as the wrist turns from neutral to supine and prone while gripping a weight or hammer.

Interval Throwing Program (Description)

The program is performed every other day, initially on level ground, finishing each step of every phase before progressing further. Pitches are “arcs,” should never be “flat” or parallel to the ground. Six phases represent different throwing distances (45, 60, 90, 120, 150, and 180 ft) with 2 steps per phase (except the 180′ phase, which includes 4 of the 14 steps total). Pitchers may then progress to throwing off the mound while other players return to their respective positions. The 120′ phase is used as a warm-up. Pitch count starts at 15 thrown off mound 50%, progressing by 15 up to 70 throws at step 5. Pitch count then varies with percentage, changing at step 6 to 45 throws off mound 50% and 30 throws off mound 75%. Pitch count and percentage increase as the athlete progresses stage 2 when fastballs are thrown off mound and during batting practice. Stage 3 adds a higher percentage for the warm-up, more throws during batting practice, and breaking balls. Numbers and percentage increase until the pitcher reaches the final step (15): a simulated game progressing by 15 throws per workout. The athlete may return to play once he or she completes the interval throwing program without symptoms. This process can take several weeks to complete.

Rehabilitation Protocol Post-reconstruction

The rehabilitation protocol used at our institution involves four phases. Phase one (weeks 1–9) begins with splint immobilization of the arm for 1 week post-operatively before transitioning to hinged elbow brace immobilization until 6 weeks later. Isotonic strengthening begins by week 3 while increasing elbow range of motion to full by weeks 5–6 and maintaining flexibility and strength of the wrist, shoulder, scapula, core, and legs. During this phase, protection of the healing UCL is key. This is accomplished by avoiding elbow valgus torque activities. Shoulder external rotation is limited until 6 weeks to prevent valgus stress on the elbow. Phase two (weeks 9–12) emphasizes stretching and strengthening of the periscapular stabilizers, rotator cuff, deltoid, legs, and core. The Thrower’s Ten Program also begins, and dynamic stabilization via the flexor-pronator muscle group becomes a focus. Phase three (weeks 13–16) continues to improve stretching and flexibility. The patient progresses to the Advanced Thrower’s Ten. Isotonic strengthening begins with bench press, seated row, lat pull-downs, triceps push downs, and biceps curls. Plyometrics begin, progressing from two-handed (2 weeks) to one-handed (2 weeks). An example of this would be bouncing a medicine ball into a trampoline. Phase four (>16 weeks) initiates a progressive interval throwing program while continuing strengthening, stretching, and the Advanced Thrower’s Ten Program. Players may return to throwing by 6–9 months. They may return to competitive throwing by 12–15 months after completing an interval throwing program and if the shoulder on the operative arm possesses greater strength than the nonoperative arm.

Rehabilitation Protocol Post-repair

The UCL repair rehabilitation protocol is similar but shorter. Phase one (weeks 1–4) begins with splint immobilization for 1 week, working to regain full ROM by 3–4 weeks post-operatively. The healing ligament is protected by avoiding activities that lead to elbow valgus torque. Flexibility and strength of the fingers, shoulder, scapula, core, and legs are maintained. Phase two (weeks 4–6) initiates isotonic strengthening of the elbow while stretching and strengthening the periscapular stabilizers, rotator cuff, deltoid, legs, and core, as well as initiating the Thrower’s Ten Program. All of the exercises are performed in the brace. Phase three (weeks 6–10) discontinues the brace, while continuing stretching and flexibility. Athletes then progress to the Advanced Thrower’s Ten while advancing weights/bands. Isotonic lifting program and plyometrics begin as described above. Phase four (>10 weeks) initiates a progressive interval throwing program and an interval hitting program while continuing to stretch and strengthen along with the Advanced Thrower’s Ten Program.

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Cummings, K., Cushman, D. & Chalmers, P. Ulnar Collateral Ligament Injuries of the Elbow. Curr Phys Med Rehabil Rep 5, 151–160 (2017). https://doi.org/10.1007/s40141-017-0156-7

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Keywords

  • Ulnar collateral ligament
  • Elbow
  • Tommy John
  • Medial elbow
  • Pitching
  • Baseball