Medial Elbow Instability & Ulnar Collateral Ligament Reconstruction in a Collegiate Baseball Player

www.fisiokinesiterapia.biz

PLAN for the day:• Brief introduction• Review of elbow anatomy• Ulnar Collateral Ligament Pathology

• Assessment• Treatment

• Surgical procedure• Case specifics

• Rehabilitation• Useful Conclusions

So…What is medial elbow instability?

• Gradual “wearing out” of the Ulnar collateral ligament, which provides most of the support to the medial side of the elbow

• Generally caused by repetitive throwing/pitching• Complete UCL ruptures would be felt with a single

pitch• Majority of athletes with UCL instability are baseball

pitchers

http://www.fauxpress.com/kimball/med/ortho/elbligm.gif

UCL Tears• Sprains are graded I, II, or III,

depending on the severity of the sprain: • grade I: pain with minimal damage

to the ligament • grade II: more ligament damage

and mild looseness of the joint • grade III: complete tearing of the

ligament and the joint is very loose or unstable.

• Because the MOI is gradual, many UCL injuries progress though the first two stages, and the athlete will finally seek treatment at stage II or III

http://www.asmi.org/asmiweb/research/

The Elbow: Joint of Mystery? …no!• The primary function of the

elbow is to allow for positioning of the hand

• The elbow is a hinge joint that is created by the humerus, the radius (lateral), and the ulna (medial)

• The “hinge” is created by the articulation of the humerus & ulna. The radius is just along for the ride.

www.digitalartform.com

Actions of the Elbow• The actions of

the elbow include flexion, extension, and rotation (pronation and supination)

http://www.pacewithlife.com

Humerus• Medial and lateral

epicondyles• Capitellum• Radial fossa• Olecranon fossa

www.digitalartform.com

Radius & Ulna• Radius

• Radial head articulates with the capitellum of the humerus

• Ulna• Articulates with the

trochlea and the olecranon fossa of the humerus

• Provides most of the bony stability of the elbow joint

1 elbow = 3 joints• The “elbow” joint is actually three

joints enclosed in one joint capsule!• Ulnohumeral (flexion/extension)• Radiohumeral (pivoting and

rotation for pronation and supination)

• Radioulnar (pivot/glide motions)www.fauxpress.com

Ligaments of the Elbow• Ulnar collateral (medial) – 3 portions

• Anterior: controls most of the valgus stress• Posterior: secondary stabilizer• Transverse: thickening of capsule - minimal joint

stability• Radial collateral (lateral)

• Connects epicondyle to annular ligament• Annular: circles the head of the radius• Interosseus: connects the medial borders of the

radius and ulna

Ligaments (cont.)

Elbow Stabilizers

85%8%Joint Capsule

5%10%RCL (lateral)

6%78%UCL (medial)

Distraction

31%33%Bone Articulation

38%10%Joint Capsule

31%54%UCL (medial)

Extension90° FlexionValgus Forces

Innervations• Ulnar nerve

• Cubital tunnel • Median nerve• Radial nerve

www.eorthopod.com

Blood Supply• Brachial Artery

• Splits into the ulnar artery and radial artery at the elbow joint

Muscles at the Elbow• Elbow flexion

• Biceps• Brachialis• Brachioradialis• Pronator Teres

• Elbow extension• Triceps• Anconeus

www.handuniversity.com

Muscles (cont.)• Wrist extensors (lateral

epicondyle)• Extensor carpi radialis

longus• Extensor carpi radialis

brevis• Extensor carpi ulnaris

• Wrist flexors (medial epicondyle)• Flexor carpi radilais longis• Flexor carpi ulnaris• Palmaris longus

www.eorthopod.com

Muscles (cont.)• Pronators

• Pronator teres• Pronator quadratus

• Supinators• Biceps brachii• Supinator

• www.health.uab.edu

Chronic UCL laxity

Mechanism of injury• Sports commonly associated with

UCL injury• Baseball• Golf• Javelin

• Repetitive movements: overhand throwing, swinging a bat, or swinging a golf club

• Motions involved in an overhand throw/pitch:• Wind up• Early cocking• Late cocking• Acceleration• Follow through

Throw that ball!

Signs and symptoms• Loss of control• Increasing pain with activity• Pain at the medial aspect of the elbow• Possible tingling/numbness due to ulnar nerve

involvement because of its location at the cubital tunnel

• Feeling of a “loose” elbow

Assessment• History

• Generally of overhead throwing• Involves description of pain, and any prior injuries

• Inspection• Palpation• ROM

• AROM, PROM, RROM• Special tests

• Valgus stress test at 30º Flexion

Differentiation of assessment• ROM is extremely helpful in

determining if there is any limitation from joint pathology• Capsular limitations (joint

effusion) will generally affect both flexion and extension equally

• Non-capsular limitations (loose bodies) will generally limit one motion more than the other

http://www.dwd.state.wi.us/dwd/publications/wc/images/f19-20.gif

Diagnostic Imaging• If the valgus stress test is positive, further

testing may be necessary to determine the severity of the UCL injury

• A study done on the efficacy of different imaging techniques found:• Magnetic Resonance Imaging (MRI)

• showed 100% full tears, 14% partial tears• Computed Tomography Arthrography

• Showed 100% full tears, 71% partial tears

Non-surgical treatment• Specific Protocol May vary, but generally follows two

phases:• Phase I

• Rest 2-3 months• NSAIDS• Ice daily 2-4 times, for 10-15 minutes• Splint to reduce pain, and decrease ROM if needed• AROM & PROM exercises for flexors and pronators

• Phase II (if pain free)• Discontinue splint/brace• Upper extremity strengthening• Throwing progression starting at 3 months• Hyperextension brace may be used

To cut or not to cut?• When are you a candidate for surgery??• Determining factors:

• Prior injuries• Time in season• Player potential

• Non-operative treatment often recommended first to avoid the long recovery associated with surgery

Surgery Decision• Usually happens after non-operative treatment

has failed • The necessity of surgery may be determined

immediately based on the situation• There needs to be a large commitment on the

athlete’s behalf because of the extensive rehab involved after surgery

Surgery Decision (cont.)• An important note:

• This decision hinges on whether or not the athlete desires to continue playing competitive or professional baseball

• Avoiding surgery has no negative effect on general lifestyle – activities of daily living

• If the athlete desires to compete in recreational sports, it will be necessary to wear a brace to protect from nerve injury because of instability in the elbow joint.

Who gets this surgery?• James Andrews

(Birmingham, AL) is one of the most renowned UCL reconstruction surgeons• Of his patients

• 20% are Major League Players

• 20-25% are Minor League Players

• The rest (roughly 60%) are college or high school athletes

reds.enquirer.com

History of UCL surgery• This surgery was invented by Dr. Frank Jobe

for pitcher Tommy John in 1974• John told his LA Dodgers team surgeon to

“make something up”• Previously, a UCL injury was career-ending to

pitchers• When the UCL is weakened and stretched, it is

considered a “dead arm” because they cannot throw at high velocities

• Dr. Jobe told John that he could “do nothing and never pitch again to try an untested surgery and still never pitch again.”

Tommy john surgery -original technique• Harvest Tendon

• Usually the palmaris longus• Transverse incision across the

wrist, another incision proximal on the forearm

• Tendon is pulled to determine that it is the correct tendon

• Tendon is removed, cleaned, and placed in saline

• If the gracilis tendon is used, it would be harvested from the leg that is not the plant foot for pitching

Procedure (cont.) • Elbow is exposed

through a (roughly) 6 inch incision

• Flexor bundle is detached

• Ulnar nerve is recognized, lifted out, and moved to provide greater access to the joint (this may cause scarring)

• Damaged ligament is located and scraped out

Procedure (cont.)• Holes drilled:

• 2 in the humerus, aimed at ulna

• I in ulna, perpendicular to the humerus

• Tendon is threaded through the holes in a figure-8 pattern, and sutured to itself http://carlykreps.tripod.com/tommyjohn/id4.html

• http://carlykreps.tripod.com/tommyjohn/index.html

Advances in the procedure• Objective: doing as little damage

as possible to the surrounding tissue

• Muscle Splitting technique:• Instead of detaching the entire

flexor bundle, the muscle splitting technique transects the flexor bundle from the medial epicondyleto 1 cm distal to the sublime tubercle of the ulna

Advances (cont.)• No nerve

transposition:• The muscle splitting

technique does not require that the ulnarnerve be moved (but it still must be identified before cutting!)

http://carlykreps.tripod.com/tommyjohn/index.html

Advances (cont.)• Bone anchor

method• Instead of drilling

through the bone, troughs are created at the UCL attachment sites, and anchors are placed on either side. The tendon graft is threaded through the anchors and attached back to itself

http://carlykreps.tripod.com/tommyjohn/index.html

Advances (cont.)• Docking procedure

• Tunnel in humerus is drilled to intersect with two smaller, perpendicular tunnels. The surgeon is able to adjust the tension of the tendon graft better than using the old tunnel technique. http://carlykreps.tripod.com/tommyjohn/index.html

Outcomes of surgery• Over time, the tendon graft “ligamentizes”

(learns to become a ligament)• The new ligament gets blood supply from the

flexor bundle and the marrow in the drill-holes• There have not been any biopsies done to see

exactly how the tissue has changed• Follow-up MRI’s show that the new tissue is

functioning as a ligament should• General opinion that pitchers are able to make

a full return to play, and even throw harder than they did before their injury

Pros and Cons• There are still some faults in the

procedure, but it has helped the sport of baseball tremendously - 1 in 9 pitchers would not be playing without it

• The outcomes are getting better and better, and clubs are getting less wary of the surgery• The Yankees signed Jon Lieber to a 2-year

contract with 3.5 million guaranteed when he was less than 5 months into his rehabilitation from surgery!)

How much is too much???• Knife happy?

• As the success rate increases, so do the number of surgeries.

• 10 years ago, doctors were more likely to recommend rest for a partial tear – now, the numbers favor surgery

• Food for thought• The non surgical success rate is lower than thought

initially: it is about a 50/50 chance it will heal with conservative treatment

• Commonly, players can be hampered with problems for years that intermittently come and go.

Rehabilitation procedure• VERY strict procedure

• Requires a full year of rehabilitation, plus another year of pitching to get back into form

• The body must have time to convert the tendon into a ligament (change from connecting tendon-bone, to bone-bone)

• The graft is very weak right after surgery, and rebuilding must be gradual

• The player may “feel good” by 7 or 8 months, but at that time, the graft is not ready to withstand the force generated in throwing

• Also important to strengthen the shoulder

Case study• 19 year of collegiate male baseball pitcher• Right hand dominant• Injury history: Asthma, resolved tibia fracture• Fall 2004 (senior year in high school)

• Experienced general elbow pain and decreased throwing speed, felt “worn out”

• 9.22.2005 (fall ball – college)• Elbow felt “tight” and pain with every pitch

• 9.26.2005• Assessed by an athletic trainer, clinical impression:

2nd degree UCL sprain

Case Study• 10.21.2005

• Assessment by Doctor #1• Mild UCL sprain – no throwing

• 11.7.2005• Assessment by Doctor #2

• UCL sprain due to chronic valgus overload• MRI results unremarkable, safe to begin rehabilitation

• 2.7.2006• Athlete assessed again by an athletic trainer, main

complaint being a decrease in overall strength and endurance

• Plan to continue strengthening program

Case Study• 2.11.2006

• Assessment by Doctor #3• Stress x-rays showed a tear in UCL

• 2.14.2006• “Tommy John” surgery to reconstruct UCL

• Used Gracilis tendon for the graft in elbow

• 2.15.2006• Athlete began his rehabilitation plan

Case Study• 3.14.2006

• 1 month post-op assessment by athletic training student• No tenderness with palpation• Some tingling in right hand with elbow extension• ROM graph

0 º145 º0 º145 ºLeft

-20º110º-20º110º*Right

Passive Extension

Passive Flexion

Active Extension

Active Flexion

Rehabilitation Program – Phase 1• Week 1

• Posterior splint at 90º elbow flexion• Wrist AROM flexion/extension• Elbow compression• Exercises

• Gripping• Wrist ROM• Shoulder Isometrics• Biceps isometrics

• Cryotherapy

Rehabilitation – Phase 1• Goals: protect healing tissue, decrease

pain/inflammation, retard muscular atrophy, protect graft site

• Week 2• Functional brace: 30º - 100º flexion • Wrist isometrics• Elbow flexion/extension isometrics• Continue week 1 exercises• Scar tissue massage• Begin Cardiovascular conditioning

• Week 3• Advance brace to 15º - 110º flexion (increase ROM 5º

extension and 10º flexion every week)

www.ikona.ca

Rehabilitation – Phase 2• Weeks 4-8

• Criteria to progress to phase 2: minimal pain and tenderness

• Goals: gradual increase in ROM, promote healing, begin to improve muscular strength

• Activities• Begin 1 lb resistance exercises for arm: wrist curls, wrist

extensions, wrist pronation/supination, elbow flexion/extension (progress through weeks 4-8)

• Rotator cuff strengthening (no external rotation until week 6) gradually progress through weeks 4-8

Rehabilitation – Phase 3• Weeks 9-13

• Criteria to progress to phase 3: full non-painful ROM, no pain or tenderness

• Goals: increase strength, power, and endurance, maintain full ROM, prepare to return to functional activities

• Activities:• Continue shoulder strengthening program and

forearm/wrist isometric program• Begin eccentric elbow flexion/extension• Begin manual resistance diagonal programs• Begin plyometric exercises with plyoball and mini tramp• Week 11: begin isokinetics

Rehabilitation – Phase 4• Weeks 14-26

• Criteria to progress to phase 4: full, non-painful ROM, 2 weeks of pain-free plyometrics, physician assessment and approval

• Goals: continue to increase strength, power and endurance of upper extremity, prepare for fully functional return

• Activities• Continue strengthening program, plyometrics, and

isokinetics• Week 22-24: initiate throwing program (see chart)• Month 11-12: possible return to competitive throwing

Current status• Athlete began throwing program at 17 weeks

post-op, but is taking the throwing program slowly

• His elbow “never hurts” when throwing, but is sore for 1-2 days after throwing

• Short-term goals are to continue with the rehabilitation and throwing programs consistently and pain-free

• The long-term goal is to play baseball in the spring

Conclusions from the case• Was surgery really necessary?

• Depends who you ask: the athlete would say YES!• Would it have healed with conservative

treatment?• Maybe/maybe not

• Determining factors• An athlete who was willing to go through the long

rehabilitation• entire college baseball eligibility to use• Personal fulfillment aspect

Whew! Review…• Introduction• Review of elbow anatomy• Ulnar Collateral Ligament Pathology

• Assessment• Treatment

• Surgical procedure• Case specifics

• Rehabilitation• Useful Conclusions

References• Starky, C., Ryan, J. Evaluation of Orthopedic and Athletic Injuries, 2nd ed. Philadelphia, PA: F. A. Davis

Company, 2002.

• Prentice, W. Arnheim’s Principles of Athletic Training. Boston, MA: McGraw Hill, 2003.

• Ellenbecker TS, Mattalino AJ. The Elbow in Sport. Champaign, IL: HumanKinetics Publishing, 1997.

• University of Michigan Health System http://www.med.umich.edu

• Ulnar Collateral Ligament Reconstruction In Baseball Pitchershttp://carlykreps.tripod.com/tommyjohn/index.html

• Altchek, DW, Hyman J, Williams R, Levinson M, Allen AA, Palletta Jr. GA, Dines DM, and Botts JD. Management of MCL Injuries of the Elbow in Throwers. Techniques in Shoulder and Elbow Surgery1:73-81, 2000.

• Azar FM, Andrews JR, Wilke, and Groh D. Operative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Athletes. The American Journal of Sports Medicine28:16-23, 2000.

• Tommy John surgery: Pitcher's best friend www.USAtoday.com

• Mirowitz, S.A., London, S.L. Ulnar collateral ligament injury in baseball pitchers: MR imaging evaluation. Radiology, Vol 185, 573-576,

• Post-operative rehabilitation protocol following ulnar collateral lignament reconstruction using autogenousgracilis graft (for ASMOC)