Ulnar Collateral Ligament

Injury and Rehabilitation in the

Overhead Athlete

Alex Caudy, SPT

Background
• Elbow injuries (specifically UCL injuries) are becoming increasingly more
prevalent in the overhead athlete
• 193% increase in UCL reconstruction surgeries in the past 10 years 1
• A survey of 6135 professional baseball players was done seeking results on
how common UCL reconstructions were currently in the game. 2 It found
that amongst responding pitchers:
• 26% of major league pitchers reported having undergone a UCL reconstruction
• 19% of minor league pitchers reported having undergone a UCL reconstruction
• And pro baseball players are not the only ones being affected by this
“epidemic”. UCL reconstructions in individuals under 18 has been on the
rise as well 3
Anatomy
• Static Restraints
• Osseus hinge joint
• Medial joint capsule
• UCL
• UCL is composed of the anterior, posterior, and
transverse bundles
• Anterior band is primary restraint to valgus
forces (stabilizes from 30-90 deg of elbow
flexion)
• Posterior band stabilizes from 90-120 deg of
elbow flexion
• Dynamic Restraints
• Flexor Pronator Mass
• This is composed of FCU, FDS, and Pronator
Teres
Risk Factors for Young Overhead Athletes4,5
• Throwing when fatigued!!!
• High Velocity
• High pitching volume
• Throwing year round
• Poor throwing mechanics
• Warm weather climates
• Pitcher/catcher combination
Immediate Treatments
• Rest and Load Management
• Non-Operative Rehab
• Reconstruction
• Repair
Non-Operative Rehab for UCL Sprains
• Around 50% of individuals with UCL injury can be treated non-surgically and return to prior level of
function 6
• Rest and anti-inflammatories
• Often includes bracing for around 3-4 weeks, depending on the severity of the sprain
• To prevent valgus stress and to limit range of motion initially
• Non-painful ROM is progressed gradually
• Muscle strengthening
• Initially consists of isometrics
• Emphasis on wrist flexors and pronators (Flexor Pronator Mass provides dynamic support for UCL)
• Thrower’s Ten
• Often not throwing for 2-3 months
• Initiated after adequate strength testing and no pain
• Platelet Rich Plasma (PRP) Injections are common
• Enhances body’s healing response, platelets have growth factors
Operative (Reconstructions)7
• Modified Jobe (Figure 8 Method)-James Andrews, MD
• FPM is spared with modified technique; is just elevated to expose UCL and
sublime tubercle of ulna
• Subcutaneous ulnar nerve transposition from the cubital tunnel
• Utilizes a series of tunnels through the medial epicondyle of humerus and
sublime tubercle of ulna; graft is then passed through these in a figure 8
pattern
• Docking Procedure- David Altchek, MD
• FPM is divided through muscle splitting technique
• Usually no subcutaneous ulnar nerve transposition
• The graft is secured/docked with a bone bridge
Operative (Repairs)8
• Typically done in adolescent and young adults with good joint stability
• Require good tissue quality; typically done only with proximal or distal
insertion tears unless the mid-substance tear is minor
• Due to surgical advances, repairs are making a comeback…
• UCL Repair with Internal Brace
• Augmentation of the original ligament with a collagen dipped tape (internal brace) and
then anchored at the proximal and distal original UCL footprints
• Surgical dissection similar to Modified Jobe (FPM elevated to expose UCL, subcutaneous
ulnar nerve transposition only in patients presenting with existing neuro symptoms)
• Healing time significantly shorter than reconstruction!! (Return to play around 5 months
as opposed to about 12 months)
Rehabilitation Following Reconstructions
• Acute Phase (Weeks 0-4)-Phase 1
• Protect healing UCL with bracing
• Decrease pain and inflammation
• Gradually restore range of motion
• Prevent Muscular Disuse Atrophy
• Wrist/hand isometrics, UE isometrics, isotonics later in phase 1
• Scapular, glenohumeral, core, and lower extremity need to be considered
• Subacute Phase (Weeks 4-10)-Phase 2
• Continue ROM and stretching
• Discontinue brace about 6 weeks
• Isotonic strengthening
• Thrower’s Ten about week 5
• Continue Core and LE program
Rehabilitation Following Reconstructions
Cont.
• Advanced Phase (weeks 10-16)- Phase 3
• Continue ROM and stretching as needed
• Advanced Isotonic Program
• Advanced Thrower’s Ten
• Emphasis on eccentric control
• Incorporate Plyometrics
• Return to Activity Phase (week 16)- Phase 4
• Light stretching program
• Advanced thrower’s ten
• Plyometrics
• Begin interval Throwing Program at about 5-6 months; off mound beginning about 9 months
• Return to competitive throwing 12-18 months
Rehabilitation Following Repairs8
• Immediate Post-Op Phase (week 1)
• Protect healing tissue with brace, reduce pain and inflammation, retard
muscle atrophy, achieve full wrist ROM
• Controlled Mobility Phase (weeks 2-5)
• Gradually restore ROM, improve muscular strength and endurance, normalize
joint arthrokinematics
• Initiate Thrower’s Ten at week 3
• Intermediate Phase (weeks 6-8)
• Restore full elbow ROM, progress UE strength, continue with functional
progression
• DC brace at week 6, initiate advanced thrower’s 10, plyometrics, core
Rehabilitation Following Repairs cont. 8
• Advanced Phase (weeks 9-14)
• Advance strengthening exercises
• Initiate interval throwing program week 12 with progression to long toss
• Continue 1 and 2 hand plyometrics
• Return To Activity/Play Phase (weeks 14+)
• Progress long toss, flat ground pitching about weeks 16-20
• Return to mound activities about week 20
• Return to competition when ready at this point
Comparison of Timelines
• Thrower’s Ten initiated much faster with repair (week 3 vs 5)
• Both discontinue brace around week 6
• Advanced thrower’s ten initiated earlier with repair (week 6 vs 10-16)
• Plyometrics initiated earlier (weeks 6 vs 10-16)
• Interval throwing program initiated earlier (week 12 vs 5-6 months)
• Return to Play earlier (about 5 months vs at least 12 months)
Outcomes3
• 83% of pitchers included in a review by Cain et al. were able to return to
the same or higher level of competition in one year following UCL
reconstruction
• 76% of MLB, 73% of minor league, and 83% of high school athletes (total n=256) 3
• 70% of repairs returned to previous level of competition or higher3
• However, this sample size was much smaller
• This new internal brace technique is not really being used with professional
athletes yet as data collection continues
• According to Wilk et al. the results are showing promise for this new repair
technique however more research is needed before it becomes more common
with pro athletes. 8
Summary
• UCL injuries are becoming much more common in overhead athletes and these
injuries are starting to become prevalent at younger ages
• About half of UCL injuries can be treated non-surgically
• If surgery is opted for, then repair or reconstruction?
• Rehabilitation following repair follows a significantly more accelerated timeline
than that of reconstruction
• Outcomes following surgical UCL treatment and subsequent rehabilitation are
overall good to great
• More research is needed on internal brace repairs, but this could be a game
changer if integrated at the professional level due to its quick return to play
timeline
References
• 1. Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of medial ulnar collateral ligament reconstruction: a 10-year
studyin New York State. Am J Sports Med. 2016;44:729-734
• 2. Leland DP, Conte S, et al: Prevalence of Medial Ulnar Collateral Ligament Surgery in 6135 Current Professional
Baseball Players: A 2018 Update. Am J Sports Med. Orthop J Sports Med. 2019 Sep 25;7(9)
• 3. Cain EL, Andrews JR, Dugas JR, et al: Outcome of UCL Reconstruction of the Elbow in 1281 Athletes. Am J Sports Med.
2010 Dec;38(12):2426-34
• 4. Fleisig GS, Andrews JR: Prevention of elbow injuries in youth baseball pitchers. Sports Health. 2012 Sep;4(5):419-24.
• 5. Olsen II SM, Fleisig GS, et al: Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports
Med. 2006 Jun;34(6):905-12.
• 6. Rettig AC, Sherrill C, Snead DS, Mendler JC, Mieling P. Nonoperative treatment of ulnar collateral ligament injuries in
throwing athletes. Am J Sports Med. 2001;29:15-1.
• 7. Looney AM, Fackler NP, Pianka MA, et al. No Difference in Complications Between Elbow Ulnar Collateral Ligament
Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis. Am J Sports
Med. 2021;3635465211023952.
• 8. Wilk KE, Arrigo CA, Bagwell MS, Rothermich MA, Dugas JR. Repair of the Ulnar Collateral Ligament of the Elbow:
Rehabilitation Following Internal Brace Surgery. J Orthop Sports Phys Ther. 2019;49(4):253-261.