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    A Case of Ulnar Collateral Ligament Instability of the Elbow

    A 21-year-old elite collegiate baseball player presents with a 6-month history of mild right medial elbow pain. When non-operative treatment fails, the author recommends right elbow UCL reconstruction.

    Author

    Michael G. Ciccotti, MD

    Disclosures

    The author has no disclosures relevant to this article.

    Background

    Injury to the ulnar collateral ligament (UCL) of the elbow was first reported by Waris in 1946. [1] Since then, multiple reports have noted the occurrence of this injury in the full spectrum of athletes, most commonly overhead throwing athletes such as baseball players. [1-4]

    During the late cocking/early acceleration phases of throwing, the valgus forces generated in the medial elbow often exceed the tensile strength of the UCL. [2,5] More specifically, studies have suggested that the anterior bundle of the UCL provides the greatest degree of medial joint stability. [4-6). Injury to this part of the UCL can result in significant pain and clinical instability (3).

    Diagnosis of the injury depends on the history and physical examination. Imaging studies, such as plain radiography, stress radiography, magnetic resonance imaging (with and without gadolinium enhancement) and stress ultrasonography, may help confirm the diagnosis. [2,3,6-9]

    Non-operative treatment a UCL injury that includes rest from throwing followed by a specific kinetic chain (legs, hips, core, upper extremity, and cardiovascular) rehabilitation program and a progressive tossing/throwing program may be successful for less-severe injuries (partial UCL injuries) in throwers or more severe injuries in non-throwers.

    Operative treatment with reconstruction of the ulnar collateral ligament and possible anterior ulnar nerve transposition (if ulnar nerve symptoms are persistent) as well as arthroscopy (if preoperative evaluation including imaging studies identify loose bodies or spurs) is often necessary in the overhead throwing athlete and in athletes or non-athletes who fail a thorough non-operative treatment program.

    The following case example illustrates a classic presentation of an athlete who incurred a UCL tear and underwent successful UCL reconstruction.

    Case Report

    Patient Presentation and History

    A 21-year-old elite collegiate baseball player presented with a 6-month history of mild right medial elbow pain. He noticed it after each game in which he pitched, but felt it resolved before his next appearance. At his last appearance, he felt a sharp increase in medial elbow pain with 1 pitch and was unable to continue.

    Physical Examination

    • Elbow range of motion from 5° to 140° degrees (compared with 0° to 145° on his non-dominant left elbow)
    • Full pronation and supination bilaterally
    • No tenderness with resisted wrist extension and forearm supination
    • Mild/moderate discomfort with resisted wrist flexion and forearm pronation, but no palpable flexor pronator tendon defect
    • Normal upper extremity neurovascular status, including normal sensation and motor strength in the right upper extremity

    Provocative Tests

    • Positive tenderness along the UCL, with valgus stress at 30° of elbow flexion
    • Positive Milking Test
    • Positive Dynamic Milking Test
    • Negative Tinel’s Sign
    • Negative Elbow Flexion Test for ulnar nerve
    • Negative ulnar nerve subluxation
    • Negative Valgus Extension Overload Test

    Imaging

    • Plain radiographs: Normal (AP, lateral, and oblique views of the right elbow)
    • MR arthrogram: High-grade partial tear of the anterior bundle of the ulnar collateral ligament with a mild flexor pronator tendon strain (Figure 1)
    • Stress ultrasonography: Partial tear of the anterior bundle of the ulnar collateral ligament with hypoechoic focii and increased joint gapping with valgus stress on the injured elbow compared with the uninjured, non-dominant elbow (Figures 2a-b)

    Figure 1. Coronal T2 MR arthrogram of the patient with a high-grade partial tear of the anterior bundle of the ulnar collateral ligament.

    Figure 2. Sonographic evaluation of the medial elbow without stress showing a high-grade partial thickness tear of the ulnar collateral ligament (left). Sonographic evaluation of the injured elbow with valgus stress applied showing increased joint space gapping (right). Large arrows outline UCL; smaller arrows denote joint space.

    Differential Diagnosis

    • Flexor-pronator strain/tear
    • Ulnar neuritis/subluxation
    • Valgus extension overload

    Diagnosis

    • High-grade partial tear of the anterior bundle of the UCL with mild-to-moderate flexor pronator tendon strain

    Treatment

    Due to the partial nature of his UCL injury, the athlete was started on a structured non-operative program. He was held from throwing for 6 weeks and was provided an initial 2-week course of non-steroidal anti-inflammatory medications. During this time, he underwent a progressive rehabilitation program, including leg, hip, core, upper extremity, and cardiovascular strengthening and flexibility training, under the guidance of a physical therapist.

    His pain completely resolved within 10 days, and at 6 weeks he began a tossing program that included playing catch at increasing distance from 30 feet up to 180 feet. At 10 weeks he initiated a throwing mound program beginning with fastballs. At 12 weeks, when he began to throw off-speed pitches, he developed recurrent medial elbow pain and was unable to continue.

    Given his recurrent symptoms despite of a thorough, structured non-operative program and his clear-cut physical and radiograph examination, it was felt that operative treatment was now appropriate.

    Operative Treatment

    The patient underwent a right elbow UCL reconstruction with ipsilateral palmaris longus autograft. Given that he had no signs or symptoms of ulnar nerve injury or subluxation, a concomitant ulnar nerve transposition was not performed. Additionally, because he had no signs or symptoms or imaging evidence of intra-articular loose bodies or spurring, no concomitant arthroscopic evaluation was performed.

    • The patient was placed the supine position, under tourniquet control and general anesthesia.
    • A 10 cm curvilinear incision was made 1 cm anterior, two-thirds distal and one-third proximal to the medial epicondyle. This was carried down through the subcutaneous tissues with care taken to identify and protect the medial antebrachial cutaneous nerve.
    • The ulnar nerve in the cubital tunnel was gently palpated but was not exposed because there was no clinical ulnar nerve pathology.
    • The flexor pronator mass was then split at the interval between the middle and posterior third’s, and gentle dissection revealed the underlying anterior bundle of the UCL (Figure 3).
    • The ligament was split in line with its fibers, revealing the joint space. Valgus stress confirmed significant laxity (Figure 4).
    • The sublime tubercle of the ulna was exposed subperiosteally, with care taken to protect the nearby ulnar nerve.
    • Two 3.5-mm drill holes were made 5 mm to 7 mm from the articular margin of the ulna, 1 anterior and 1 posterior to the sublime tubercle with a 1 cm bridge (Figure 5). The tunnels were connected with a curette.
    • A 4.5-mm drill bit was used to create a single, close-ended tunnel in the medial epicondyle of the humerus, midway between the tip and base of the epicondyle, just along its anterior surface (the isometric point for the anterior bundle of the ulnar collateral ligament).
    • The flexor pronator mass was split at the junction of the middle and anterior thirds, revealing the supracondylar ridge of the humerus.
    • Two 3.5-mm drill holes were then created with a 1 cm bridge and converging on the close-ended 4.5-mm tunnel. This created a “Y tunnel configuration in the medial epicondyle (Figure 6). Graft-passing 22-gauge wires were then placed.
    • The ipsilateral palmaris longus tendon was harvested through 3 1-cm incisions placed at the wrist crease, 7.5 cm proximal and 15 cm proximal, respectively. A non-absorbable suture was placed in a modified Krakow fashion through both ends of the graft.
    • The graft was then placed in a figure-of-8 fashion and sutured on itself with the elbow at 30° of flexion and the forearm in neutral rotation (Figure 7).
    • The remnant of the native UCL was repaired over the reconstruction. The flexor pronator interval splits were repaired and a routine closure was carried out for all incisions.

    Figure 3. The anterior bundle of the ulnar collateral ligament seen through the longitudinal split of the middle and posterior thirds of the flexor pronator mass.

    Figure 4. Significant gapping of the ulnar humeral joint with valgus stress applied seen through the longitudinal split in the anterior bundle of the ulnar collateral ligament.

    Figure 5. Two 3.5-mm tunnels created anterior and posterior to the sublime tubercle.

    Figure 6The 4.5-mm close-ended tunnel and the 2 3.5-mm tunnels in a “Y” configuration in the medial epicondyle of the humerus.

    Figure 7. Figure-of-8 reconstruction of the anterior bundle of the ulnar collateral ligament with ipsilateral palmaris longus autograft.

    Postoperative Treatment

    • A soft dressing was applied followed by a plaster splint with the elbow in 90° of flexion and the forearm in neutral rotation.
    • At 10 to 14 days postoperatively, a hinged brace was applied and therapy was initiated. Gentle range of motion and isometric strengthening exercises were started. Leg, hip, core, shoulder, and cardiovascular training were initiated simultaneously.
    • At 6 weeks, the brace was removed and strengthening progressed.
    • At 3 months postoperatively, batting was allowed.
    • A tossing program was initiated at 4 months postoperatively
    • A mound throwing program was begun at 6 months, but return to competition occurred at 14 months postoperatively.

    Final Follow-up

    • At 18 months postoperatively, the player had returned to full competition as a collegiate pitcher. His velocity and control were restored and he was then drafted into professional baseball.

    As was seen with this pitcher, reconstruction of the UCL has shown to be highly successful in returning overhead or throwing athletes to their pre-injury level of performance. [10-13]

    Author Information

    Michael G. Ciccotti, MD, is Director of the Sports Medicine Team at The Rothman Institute, Philadelphia, Pennsylvania. He is a Professor of Orthopaedic Surgery, Chief of Sports Medicine, and Director of the Sports Medicine Fellowship at Thomas Jefferson University. He serves as Head Team Physician for the Philadelphia Phillies and St. Joseph’s University.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Fotios P. Tjoumakaris, MD

    References

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    5. Morrey BF, Tanaka S, An KN. Valgus stability of the elbow; a definition of primary and secondary constraints. Clin Orthop Relate Res. 1991;265:187-195.
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