Ulnar Collateral Ligament Injuries of the Elbow

Ulnar Collateral Ligament Injuries of the Elbow

By: Daniel P. Bouvier, MD

Introduction

Elbow injuries in adolescent athletes have gained quite a bit of attention over the last decade with increased sports participation, physician awareness, and media attention. There has also been an alarming rate of increased surgical procedure performed in younger athletes in that timeframe.

What is it?

The ulnar collateral ligament is a 3 part ligament on the inside part of the elbow that connects the upper arm to one of the forearm bones (ulna). It provides stability to the hinge joint of the elbow resisting the outward directed stress placed on the elbow during the throwing motion. Pitching a baseball has been shown to generate forces at the elbow very close to the ultimate strength of the ulnar collateral ligament, which over time and repetition, can lead to failure of the ligament.

Symptoms

Some patients may report an actual “pop” felt while throwing, which would represent an acute (sudden) injury to the ligament. Many others will describe a vague pain, consistent in its location and during the late cocking and early acceleration phase of the throwing motion. This is more consistent with a chronic attenuation (thinning) of the ligament. Some may also describe some nerve symptoms, such as numbness or tingling into the fingertips (from the ulnar or “funny bone)nerve). It’s important to also know the patients history of position played, frequency of play, number of pitches, prior treatments and offseason regimen.

Risk Factors

Four potential risk factors for elbow (and shoulder) injuries in youth baseball have been identified: Number of pitches thrown (in a game, season, and year), type of pitches, pitching mechanics, and physical condition. The number of pitches thrown seems to be the most important. Recent studies have suggested that the curveball may not be any more dangerous than any of the other pitches, and that the change up is likely the safest. Pitch counts were mandated by Little League Baseball many years ago based on these studies and can be found at www.littleleague.org. Pitching outside of the league makes tracking some of these things difficult, as many young athletes will play on multiple teams in different leagues who may not follow these guidelines.

Testing

The first testing should be a thorough physical exam by a Sports Medicine Fellowship trained Orthopaedic Surgeon. If an ulnar collateral ligament injury is suspected, after some screening x-rays are performed, an MRI scan may be warranted. This is a test that will demonstrate the soft tissues around the elbow.

Treatment

A trial of non-surgical management is encouraged, especially in the young adolescent athlete. This usually consists of at least 6 weeks of no throwing as we begin physical therapy. There are often many areas of deficiency to address, including motion deficits of the shoulder, pitching mechanics, weakness of the core and kinetic chain (the center of the body (hips, abdominal, gluteal, back) and legs) as well as the shoulder. Once these deficits have been identified and addressed, then a VERY gradual, SUPERVISED throwing program may begin. The patient must remain pain free through this course and progression to be able to return to competition. In the event that this fails, or that the tear is complete on evaluation, surgery may be required if the patient is still planning to play, and to pitch. Surgery is reconstructive, which means the ligament is replaced by a tendon graft connecting the two bones. Often a tendon from the forearm or the opposite hamstring (at the knee) is used. Rehabilitation is long and deliberate and a return to competitive throwing is expected 9-12 months after surgery. Outcomes from surgery reveal a very high rate of return to the same level of competition. However, a very recent report from the American Orthopedic Society for Sports medicine in Major League pitchers shows a trend toward a higher ERA, WHIP (walks and hits per inning pitched), and innings pitched thereafter. Very few, if any, adolescent pitchers requiring this surgery will ever make it to the Major League level. Below are some useful guidelines from USA Baseball.