Medial Elbow Instability & Ulnar Collateral Ligament Reconstruction in a Collegiate Baseball Player
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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
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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.
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Actions of the Elbow• The actions of
the elbow include flexion, extension, and rotation (pronation and supination)
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Humerus• Medial and lateral
epicondyles• Capitellum• Radial fossa• Olecranon fossa
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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
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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
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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
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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)
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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)