While there are several ligaments that help support the elbow joint, the most commonly injured is the UCL (Ulnar Collateral Ligament). These injuries are usually a result of repetitive stress from overhead motions.
UCL tears are often associated with sports like baseball and have become more commonly known as “Tommy John” injuries – named after the famous Los Angeles Dodgers pitcher who first received UCL reconstruction surgery in 1974. These injuries are increasing in frequency among high school and amateur pitchers, with UCL reconstruction becoming one of the most common surgeries in overhead-throwing athletes. It is especially common in baseball, where 25% of Major League pitchers and 15% of Minor League pitchers have received this surgery at some point in their careers. For many athletes, Tommy John surgery may be the best treatment option to get them back in the game.
What is the UCL?
Ligaments are strong bands of connective tissue that connect one bone to another to help stabilize a joint. The ulnar collateral ligament (UCL) is located on the medial side (pinky side) of the elbow and helps support the joint so it can bend, straighten, rotate and twist. The UCL spans from the medial aspect of the humerus (the bone of the upper arm) to the medial side of the ulna (one of the bones in the forearm) and consists of three bands: the anterior bundle, posterior bundle, and transverse bundle. The anterior bundle is the strongest stabilizer for valgus force, i.e. force applied on the inside of the elbow, and is, therefore, the most frequently injured.
The UCL plays a vital role in stabilizing the elbow during overhead throwing motions, so it must be strong enough to withstand a great amount of stress. However, this repeated stress can cause the ligament to be overstretched or torn.
Causes of injury
Daily activities typically do not put sufficient stress on the UCL to cause injury. Rather, UCL tears are generally the result of overuse from repetitive motions. This repetitive stress can cause microscopic tears or inflammation that result in the tearing of the ligament. UCL tears are most commonly seen in baseball pitchers or other athletes who perform repetitive overhead motions (javelin, tennis, etc.) because of the strong repetitive force on the inside of the elbow that these motions require. Chronic UCL tears usually present as a gradual onset of inner elbow pain during the acceleration phase of throwing (see Figure 2), or pain after a period of overhead throwing.
While less common, a traumatic blow to the outside of the elbow or fall on an outstretched arm can overload the ligament and cause it to tear. This acute (sudden onset) injury can happen in sports like gymnastics, wrestling, football, or other contact sports. It is usually associated with a “popping” sound and an immediate feeling of pain.
Unfortunately, there has been a dramatic increase in UCL injuries at all competition levels, with some sports medicine doctors referring to it as the Tommy John epidemic. This is likely due to the increasing velocity, volume, and frequency of throwing as many athletes participate in year-round activity with inadequate rest. These have been identified as the strongest risk factors for developing a UCL injury, and there is an ongoing effort amongst researchers and sports medicine doctors to find ways to combat this increase.
Signs of a UCL tear
The most common symptom of a UCL tear is pain on the inner side of the elbow. This is usually following a period of repetitive throwing or overhead activity, particularly while accelerating the arm forward. An athlete may also notice a decrease in athletic performance, such as loss of endurance, speed, control, and accuracy. If the nerves around the ligament are injured, some athletes may also experience weakness, numbness, or tingling in the pinky and ring fingers. In cases of acute injury, there is often a sudden “pop” in the arm, followed by pain and swelling.
When to see a doctor:
If you are experiencing symptoms of a UCL injury, it might be time to consult with your sports medicine doctor. This is important to get an accurate diagnosis and to establish an effective treatment plan to get you back in the game.
Your doctor will collect a full medical history, evaluate your symptoms, and examine your elbow. The most common test when investigating a UCL injury is called a valgus stress test, which assesses the integrity of your elbow. A doctor will put valgus force on the elbow and look for instability in the joint and for signs of pain (see what a valgus stress test looks like here).
Often, a sports medicine physician can evaluate the UCL with ultrasound to visualize the ligament dynamically while performing the valgus stress test. An X-ray may be obtained to rule out any fracture to the surrounding bones, and an MRI or CT scan may also be used to thoroughly evaluate the degree of UCL injury.
Based on symptoms and the doctor’s evaluation, a UCL injury will be graded on a scale of 1 to 3:
Grade 1: the ligament is overstretched, but not torn.
Grade 2: the ligament is overstretched with a partial tear.
Grade 3: the ligament is completely torn.
Treatment for UCL tears will depend on the severity of the injury and should be tailored to each individual. In many cases – particularly for partial tears or those who are not overhead throwers – a conservative treatment approach will be taken to reduce pain and swelling and stabilize the elbow. This could include rest, ice, and the use of pain or anti-inflammatory medications (aspirin, ibuprofen, naproxen, etc). Physical therapy is also important to strengthen the muscles around the elbow to help compensate for the torn ligament. Generally, younger athletes tend to have less severe UCL injuries than older athletes and are more likely to be treated conservatively.
In some cases, partial UCL tears can be treated with PRP (protein rich plasma) or prolotherapy. These injections can aid the healing of the ligament especially when conservative treatments are not helping. If there is a complete tear of the ligament or conservative treatment fails, surgery may be recommended. This is often preferred for high-level throwers that want to return to competition. An orthopaedic specialist can perform either a UCL repair, which involves sewing and anchoring the ligament back down to the bone, or UCL reconstruction, which uses a tendon from somewhere else in the body (or from a donor) as material to repair the damaged ligament. More commonly known as Tommy John surgery, the goal of UCL reconstruction is to restore the original function of the ligament.
If surgery is not required, UCL tear recovery could take anywhere from several weeks to months. For throwers, 2-3 months of no throwing or overhead activities is recommended, while non-throwers should be able to resume normal activities when they are pain-free. It is important to work with your sports medicine doctor to develop a rehabilitation program with the ultimate goal of restoring elbow function in a safe and pain-free way.
For UCL injuries that require Tommy John surgery, rehabilitation can take anywhere from 9 months to a year. Immediately after surgery, rest is critical, and the elbow will be put in a splint in order to limit movement. After a couple of weeks, it will be placed in a brace that allows an increasing range of motion until the elbow can be fully extended; however, it is important that stress on the elbow is avoided for at least the next 4 months. In the final phase of rehabilitation, the patient should work with their sports medicine doctor and physical therapist to strengthen the elbow so it can handle the stress of returning to play. They will likely be given an interval throwing program to gradually increase the distance, volume, and intensity of throws over a period of time, with the average pitcher returning to gameplay an average of 12-16 months after surgery.
Once considered a career-ending injury for professional athletes, the outlook for most patients with UCL injuries is positive. Improvements in reconstruction techniques and rehabilitation programs have resulted in high rates of return to sport, with 80-93% of overhead athletes eventually able to compete at pre-injury performance levels.
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