Ulnar Collateral Ligament Tear in a Collegiate Baseball Pitcher
An 18-year-old pitcher presents with pain in the medial aspect of the right elbow following a specific pitch. MRI demonstrates a full-thickness tear of the distal aspect of the ulnar collateral ligament. What is the next step?
Brandon J. Erickson, MD
Ulnar collateral ligament (UCL) tears of the elbow have become more common in overhead athletes over the past 10 years, [1-3] with recent studies showing that approximately 25% of professional baseball pitchers have undergone UCL reconstruction. [4,5] Many risk factors for UCL injury have been identified, including workload, training with weighted baseballs, and fastball velocity. [6-8] The UCL functions as the primary restraint to valgus stress at the elbow, contributing approximately 50% of the medial elbow stability. [9,10] The UCL is constantly at risk for damage in overhead athletes, given the amount of stress exerted on it with each overhead throw.
Several treatment options are available for UCL tears, including non-operative management, biologic augmentation to non-operative management, UCL repair, and UCL reconstruction. [11-18] Treatment for UCL tears is patient-specific, with multiple factors taken into consideration when deciding on the best treatment for the athlete. Patient age, tear pattern, location of the tear, and many other factors are discussed when determining the ideal treatment for a specific patient. The ultimate goal of treatment is to allow the player to return to sport at the same or higher level as before the injury.
An 18-year-old male collegiate baseball pitcher presents 1 week after experiencing significant pain in his right elbow, which started after he threw a fastball in a game. He felt the pain immediately as he let the ball go.
The patient does not have any pain or discomfort in his shoulder, and he denies any numbness or tingling in his arm and hand. He also denies any prior complaints with this arm. He has had no prior surgeries on his shoulder or elbow.
He states that he stopped throwing after this recent injury and he now has very little pain in the elbow. He would like to be able to return to sport at a high level.
- Height: 6 feet, 1 inch; weight: 190 pounds; BMI: 25.1 kg/m2
- No significant ecchymosis on inspection
- Full range of motion of the elbow
- No pain on forced terminal extension
- Negative arm bar and bounce test
- No pain with resisted wrist flexion or forearm pronation
- Positive moving valgus stress test
- Positive milking maneuver
- Negative Tinel’s at the elbow
- Neurovascularly intact distally
Radiographs of the elbow do not show any osseous abnormalities. MRI of the right elbow demonstrates a Grade 3B (complete, distal) tear of the UCL (Figure 1).
Figure 1. Coronal T2 MRI demonstrating a full–thickness tear of the distal UCL (arrow). Note that the distal UCL is completely torn off the sublime tubercle and is several millimeters displaced.
One thing to keep in mind when evaluating an MRI of the elbow: The position of the elbow is critical for proper visualization of the UCL. If the elbow is rotated, it can severely obscure the UCL and make it very difficult to properly evaluate the MRI.
- Full-thickness tear of the distal UCL
The options presented to the patient included:
- Non-operative treatment with rest and a return to throwing program
- Biologic augmentation with platelet-rich plasma
- Operative treatment with surgical repair or reconstruction of the torn UCL
Non-operative treatment would not be successful in this patient, due to the tear type and location, we felt that. [19-21] We discussed both UCL repair and UCL reconstruction with the patient, and given his age, the location of the tear, and the apparent excellent tissue quality, we felt he would do well with UCL repair. However, we made it clear that the decision to proceed with UCL repair would be made during the procedure. We told the patient that if his UCL tissue quality was not good, we would proceed with UCL reconstruction.
The patient had an ipsilateral palmaris longus, which we would use as the graft if UCL reconstruction was necessary. He had no ulnar nerve symptoms and no evidence of posteromedial impingement, which meant we would not need to perform an ulnar nerve transposition or elbow arthroscopy.
We discussed the nature of UCL repair and the associated risks, including injury to the ulnar nerve, potential wound complications, and possibility of re-tear, as well as the postoperative recovery and rehabilitation protocol. The patient communicated his understanding of the risks, and after further discussion with the patient, coaching and training staff, agent, and family, the decision was made to proceed with surgical repair.
- The patient was given a nerve block and general anesthesia.
- Preoperative antibiotics were given, and a tourniquet was placed high on the right arm.
- The patient was prepped and draped in the usual sterile fashion. After a timeout, the tourniquet was inflated to 250 mmHg.
- A skin incision was made beginning slightly proximal to the medial epicondyle and heading distal down the forearm.
- Dissection was taken down to the fascia overlying the flexor pronator mass. Great care was taken to avoid damage to the medial antebrachial cutaneous nerve (MABCN) (Figure 2). Note that the MABCN is identified by the scissors in Figure 2.
Figure 2. Intraoperative image demonstrating exposure of the flexor pronator mass. Care was taken to identify the MABCN, shown at the tip of the scissors.
- The flexor pronator mass was then split in line with its fibers and dissection was taken down to the native UCL.
- Once the native UCL was isolated, a longitudinal split was made within the UCL, and medial joint gapping was confirmed (Figure 3).
Figure 3. Intraoperative image demonstrating a longitudinal split in the native UCL, which exposes the medial joint gapping (circle).
- The UCL repair portion of the tear was now performed. The first anchor was placed distally at the sublime tubercle, as this patient had a distal UCL tear. The anchor was placed so that its most proximal portion was 3 mm to 4 mm distal to the joint line. This would avoid any potential for breaking into the joint.
- To place the anchor, a pilot hole was drilled and then tapped. The 3.5-mm anchor (Peek SwiveLock, Arthrex; Naples, Florida) was inserted. The anchor was loaded with a high-tensile, collagen-coated tape suture (InternalBrace technique, Arthrex; Naples, Florida), as well as a high-tensile repair stitch.
Figure 4. Intraoperative image demonstrating placement of the distal anchor loaded with high–tensile tape and a repair stitch.
- Once the anchor was placed, the UCL repair was performed. The high-tensile suture was then passed through the torn portion of the native UCL to repair the UCL back down to bone. This completed the repair portion of the case.
- The location for the second anchor was exposed. In this case, the second anchor was placed proximally to expose the medial epicondyle. The origin of the UCL on the medial epicondyle was then exposed and the bone was prepared for the anchor. The hole was first drilled and then tapped (Figure 5).
Figure 5. Intraoperative image demonstrating placement of the proximal anchor. The tap for the proximal anchor has been placed.
- Before the anchor was placed, the split in the native UCL was repaired with several simple interrupted sutures.
- The collagen-dipped tape suture was then loaded into the second 3.5-mm anchor (Peek SwiveLock, Arthrex). Care was taken not to over-constrain the tape suture. An elevator can be placed underneath the tape to reduce the risk of over-constraint.
- Once the anchor was placed, the elbow was taken through a full range of motion (ROM) to confirm that the tape was not too tight (Figure 6).
Figure 6. Intraoperative image demonstrating the final construct of the repaired UCL and the tape suture, which sits superficial to the UCL.
- With full ROM confirmed, high-tensile sutures were used to sew together the native UCL and the tape suture to ensure that they would move as a single unit.
The goal of the first 6 weeks post-surgery is to allow the ligament to heal down to bone. Below is the postoperative protocol the author has found to be effective. Athletes should understand that recovery to their optimal level of play takes about 6 to 7 months. Some may progress faster, while others may be slower, but this is a general guideline.
- Immobilize the elbow in a hinged elbow brace at 75° flexion for 7 to 10 days, wrist free, with a sling.
- Change the dressing 7 to 10 days after surgery.
- Begin active ROM in the brace.
- Adjust the brace to 15° (locked) extension to full flexion.
- Begin grip strengthening in the brace.
- Discontinue use of the hinged elbow brace.
- Advance from passive shoulder and elbow ROM to active assisted ROM to active ROM as tolerated.
- Progress to 0° to 145° of elbow ROM (full motion).
- Begin muscle strengthening exercises for the wrist, forearm, elbow, and shoulder (Throw Ten Program).
- Advance strengthening as tolerated.
- Avoid aggressive weight-lifting (eg, chest flies or lifts that stress the ligament) until 8 weeks post-surgery.
- Incorporate total body conditioning/aerobic training into the exercise routine.
Month 3 / Week 12
- Begin an interval-throwing program, progressing from 45 feet up to 180 feet.
- Pitchers should not throw past 120 feet; infielders should not throw past 150 feet.
- Progress from one distance level to the next when the following criteria are met: No pain or stiffness while throwing; no significant pain or stiffness after throwing; good strength throughout the final set, with little fatigue; effortless and fundamentally sound throwing motion; consistent accuracy and online throws.
- A mound program for pitchers begins at the completion of the 120 ft level.
- The catcher is initially moved forward, but throwing with a pitching motion is reserved for the mound.
- Flat ground pitching is not allowed.
- Return to competition is permitted when the following conditions are met:
- Trunk, scapula, shoulder, and arm muscle strength and balance have returned to normal
- No pain while throwing
- Throwing balance, rhythm, and coordination have been reestablished
- A thorough preoperative discussion is critical in cases of UCL repair. The patient must understand that while the plan is to perform a UCL repair, the decision may be made to perform a UCL reconstruction if the UCL tissue quality is poor. Furthermore, it is important to discuss graft choice with the patient preoperatively. It is critical to know whether the patient has an ipsilateral palmaris longus to avoid any inadvertent harvest of the median nerve.
- The MABCN often crosses the surgical field at its most distal aspect. Great care should be taken to protect this nerve.
- The first anchor is placed where the tear is: If there is a distal tear, the first anchor is placed distal; if there is a proximal tear, the first anchor is placed proximal. The distal anchor should be placed such that a few millimeters of space is left between the anchor and the joint to prevent any breakage into the joint. The proximal anchor should be placed at the UCL origin on the medial epicondyle, which is relatively deep in the incision. Placing this anchor too superficial runs the risk of a medial epicondyle fracture.
Ulnar collateral ligament tear has become an increasingly common injury in overhead athletes, specifically baseball pitchers, over the last 10 years. [3,22,23] Although many patients who sustain a UCL tear should have a trial of non-operative treatment, some imaging characteristics are associated with poor outcomes of non-operative management.
Frangiamore et al  evaluated MRI characteristics that were predictors of failure in 32 professional baseball pitchers with UCL tears who underwent a trial of non-operative treatment. Two thirds of pitchers (66%; 21/32) successfully returned to sport without undergoing UCL reconstruction, while 34% failed non-operative treatment and required subsequent UCL reconstruction. 
The likelihood of a player failing non-operative treatment was 12.40 times greater with a distal tear: In the study by Frangiamore et al,  82% of pitchers who failed non-operative treatment had a distal tear. Furthermore, when combining a high-grade tear and distal tear location, 88% (7/8) failed non-operative treatment.
The patient in this case had an acute, full-thickness distal UCL tear. As such, we discussed both operative and non-operative treatment, but the player ultimately decided on surgery, given the risk for failure with non-operative treatment.
He was an ideal candidate for UCL repair as he was relatively young, had a complete distal tear, and had excellent-quality tissue in his UCL. Although UCL repair with InternalBrace augmentation is emerging as an excellent procedure for many of these players, it must be noted that not all players with UCL tears are candidates for UCL repair. Older players with a tissue-deficient UCL, those with a midsubstance tear, or those with tears in multiple locations are better served with UCL reconstruction than with UCL repair.
The new UCL repair with the InternalBrace augmentation technique was first described by Dugas et al,  who performed biomechanical testing on the new technique and found that UCL repair with InternalBrace augmentation replicated the time-zero failure strength of traditional UCL reconstruction and appeared to be more resistant to gapping at low cyclic loads.
Following this proof of the stability of the new technique, Dugas et al  reported on the outcomes of the first 111 overhead athletes (all under 22 years old) who underwent UCL repair with InternalBrace augmentation. The patients had all failed non-operative treatment, had imaging suggestive of a complete or partial UCL avulsion from the sublime tubercle or medial epicondyle, and had good-quality ligament tissue. More than 90% of players (102/111) returned to sport at the same or higher level at an average time of 6.7 months. 
The ability of these athletes to return to sport at less than 7 months is game-changing. It typically takes players 12 to 18 months to return to sport following UCL reconstruction. Being able to offer this alternative procedure to certain players is extremely beneficial.  Further work is needed to determine the mid- to long-term outcomes following UCL repair.
Brandon J. Erickson, MD, is an orthopaedic sports medicine and shoulder surgeon at The Rothman Orthopaedic Institute, New York, New York. He is also the Sports Medicine Editor for Rothman Institute Grand Rounds.
Disclosures: Dr. Erickson has no disclosures relevant to this article.
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