Elbow specialist compares treatments for UCL tears in overhead athletes

KOHALA COAST, Hawaii — Athletes who perform repetitive overhead throwing motions are particularly prone to injuring their ulnar/medial collateral ligament of the elbow, especially when they place undue stress on the ligament due to an ineffective throwing mechanism.

The ulnar collateral ligament (UCL) in the elbow includes anterior, posterior and transverse bundles. The anterior bundle of the ligament functions as the main medial stabilizer of the elbow, “and it is this bundle that absorbs much of the valgus stress in throwing motions. As a result, injuries to the anterior bundle of the ligament are a frequent source of morbidity and lost playing time in throwing athletes, and it’s the one we are most concerned about in throwers,” said Neal S. ElAttrache, MD, who discussed the topic at Orthopedics Today Hawaii 2009, here.

While some athletes will need surgery, orthopedic surgeons should first prescribe rest, especially if the patient is not a professional or highly competitive athlete, he said.

This nonoperative treatment should include active rest for at least 6-8 weeks and as much as 3-4 months for more severe cases. It can also include progressive elbow and shoulder rehabilitation as well as an interval throwing program, where the athlete gradually increases his or her throwing over several weeks and months, ElAttrache said.

“It’s important to remember that the repetitive throwing motion can cause damage to the soft tissue as well as to the skeleton,” he said.

He also said valgus stress radiographs can be helpful, “but the MRI scan is the best scan we have to identify these injuries radiographically.”

For more severe cases, orthopedic surgeons can either repair or reconstruct the ligament. According to ElAttrache, UCL reconstruction is often more effective than repair for high-caliber adult throwing athletes, and joint pathology can be treated either open or arthroscopically.

He also recommended checking patients’ range of motion during their exam and noting any impaired range of motion, although having a restricted ROM does not guarantee the presence of a UCL tear, he said.

ElAttrache cited the docking procedure introduced by David Altchek, MD, and his own DANE procedure, which involves a single ulnar drill hole, a biotenodesis screw for fixation and a proximal docking technique, as two reconstruction approaches that have worked for competitive athletes.

Although surgeons should always consider nonoperative and noninvasive treatment for these athletes first, “some studies have shown that about 85% of throwers return to play after their UCL reconstruction,” he said.

Ultimately, a reconstruction technique will be effective if it allows for the limited dissection and handling of the ulnar nerve (ie, muscle splitting), anatomic replacement, and reproducible tensioning and fixation, ElAttrache added.

Reference:
ElAttrache NS. Ulnar collateral ligament tears: Update. Presented at Orthopedics Today Hawaii 2009. Jan. 11-14, 2009. Kohala Coast, Hawaii.