Updated: 5/1/2020

Medial Ulnar Collateral Ligament Injury (Valgus Instability)

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https://upload.orthobullets.com/topic/3079/images/docking_depiction..jpg
Introduction
  • Overview
    • attenuation or rupture of the ulnar collateral ligament of the elbow leading valgus instability in overhead throwing athletes
      • traditionally treated with ligamentous reconstruction
  • Epidemiology
    • incidence
      • literature shows increasing occurrence of UCL injuries and reconstructions
      • becoming more common among high school and amateur pitchers
    • demographics
      • overhead athletes who place significant valgus stress on their elbows
      • originally described among javelin throwers, now much more common in baseball pitchers
      • relatively uncommon in skeletally immature throwing athletes 
        • little leaguers' elbow
          • more common cause of medial elbow pain with decreased throwing effectiveness and distance 
    • risk factors
      • exceeding youth baseball pitch count and inning restrictions
      • higher pitch velocity
      • deficits along kinetic chain (shoulder and core weakness, loss of shoulder motion, etc.)
  • Pathophysiology
    • mechanism of injury
      • acute trauma
        • often associated with elbow dislocations
      • overuse injury
        • biomechanical forces
          • microtrauma from repetitive valgus stress leads to rupture of the anterior band of the medial UCL 
          • baseball pitchers place significant valgus stress on the elbow in the late cocking and early acceleration phase of throwing      
          • elbow valgus load increases with poor throwing mechanics and decreases with trunk-scapular kinesis, forearm pronation, dynamic flexor-pronator stabilization
          • valgus load is highest in the acceleration phase of throwing
      • iatrogenic
        • excessive olecranon osteophyte resection places the MCL at risk
  • Associated conditions 
    • traction-related ulnar neuritis
    • olecranon (posteromedial) impingement
    • elbow arthritis
  • Prognosis
    • formerly a career-ending injury 
    • UCL reconstruction provides high rates of return to throwing and sport 
      • worse outcomes following revision reconstructions
Anatomy 
  • Osseous
    • elbow is complex hinge composed of ulnohumeral, radiocapitellar, and radioulnar joints
    • valgus carrying angle ranging from 6 to 11 degrees
  • Ligaments
    • medial ulnar collateral ligament (UCL)
    • divided into three components
      • anterior oblique ligament  
        • strongest and most significant stabilizer to valgus stress    
        • courses from anteroinferior ridge on medial epicondyle to 2.8 mm distal to the ulna articular margin on the sublime tubercle
        • mean length of 54 mm
        • subdivides into anterior and posterior bands.
          • anterior band is primary restraint to valgus stress, exhibiting nearly isometric strain during elbow ROM  
          • posterior band exhibits increasing strain during higher degrees of elbow flexion
      • posterior oblique ligament (posterior bundle)
        • demonstrates the greatest change in tension from flexion to extension 
        • tighter in flexion
      • transverse ligament
        • no contribution to stability
  • Biomechanics  
    • elbow stability evenly split between osseous and soft tissue structures
    • UCL primary restraint to valgus stress from 30 to 120 degrees of flexion
      • flexor-pronator and joint capsule also contribute
Presentation
  • History
    • acute injuries may present with a "pop" associated with pain and difficulty throwing
  • Symptoms
    • decreased throwing performance
      • loss of velocity
      • loss of control and accuracy
    • pain
      • medial or posterior elbow pain during late cocking and acceleration phases of throwing
      • many throwers also have posteromedial pain due to valgus extension overload felt during the deceleration phase
    • ulnar nerve symptoms
      • paresthesias down ulnar arm into ring and small fingers
  • Physical examination
    • inspection
      • tenderness along elbow at or near MCL origin
        • posteromedial tenderness may be due to valgus extension overload
      • evaluate the integrity of the flexor-pronator mass
      • evaluate for presence of palmaris longus tendon
    • range of motion
      • seasoned throwers may lack full extension 
      • evaluate shoulder and rest of kinetic chain
    • neurovascular
      • evaluate for ulnar neuropathy and/or subluxation
    • provocative tests
      • valgus stress test
        • flex elbow to 20 to 30 degrees (unlocks the olecranon), externally rotate the humerus, and apply valgus stress
        • 50% sensitive
      • milking maneuver 
        • creates valgus stress by pulling on the patient's thumb with the forearm supinated and elbow flexed at 90 degrees
        • patient may be supine or seated/standing
        • positive test is a subjective apprehension, instability, or pain at the MCL origin
      • moving valgus stress test post  
        • place elbow in same position as the "milking maneuver" and apply a valgus stress while the elbow is ranged through the full arc of flexion and extension
        • positive test is a subjective apprehension, instability, or pain at the MCL origin between 70 and 120 degrees  
        • 100% sensitive and 75% specific 
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of the elbow
        • static x-rays are often normal
        • may show loose bodies or calcifications of UCL
    • optional views
      • oblique views to evaluate the olecranon
      • gravity or manual stress radiographs of both elbows  
        • may show medial joint-line opening >3 mm (diagnostic)
    • findings
      • assess for a posteromedial osteophyte (due to valgus extension overload)
  • MRI
    • indications
      • high suspicion for UCL injury and/or intra-articular pathology
    • MR-arthrogram - diagnostic 
      • use of dye more accurate
      • sensitivity 92%, specificity 100%
    • findings  
      • thickened ligament (chronic injury), calcifications, and tears
      • midsubtance tears or proximal/distal avulsions
      • full-thickness or partial undersurface tears
      • capsular "T-sign" with contrast extravasation
  • Dynamic ultrasound
    • can evaluate laxity with valgus stress dynamically
    • sensitivity and specificity operator dependent
Differential
  • medial epicondylitis  
  • flexor-pronator strain  
  • ulnar neuropathy  
  • valgus extension overload  
Treatment
  • Nonoperative 
    • Rest and physical therapy
      • indications
        • first line treatment in most cases  
        • partial tears
      • outcomes
        • 42% return to preinjury level of sporting activity at an average of 24 weeks
  • Operative
    • UCL anterior band ligament reconstruction (Tommy John Surgery) 
      • indications
        • high-level throwers that want to continue competitive sports
        • failed nonoperative management in partial tears and willing to undergo extensive rehabilitation
      • outcomes 
        • 90% return to preinjury levels of throwing with newer reconstruction techniques
        • humeral docking associated with better patient outcomes and lower complication rate compared to figure-of-8 fixation 
        • humeral docking has shown higher rates of return to sport compared to Jobe and modified Jobe techniques 
        • humeral docking and cortical button techniques are biomechanically stronger than figure-of-8 and interference screw fixation
        • humeral docking with interference screw fixation on the ulnar side showed 95% strength of the native UCL
    • UCL repair
      • indications
        • not clarified in the literature
        • mostly performed in young athletes with avulsion-type tear patterns
      • outcomes
        • originally performed with poor results, replaced by reconstruction
        • multiple, recent case series show promising results with novel, augmented techniques
Techniques
  • Rest and physical therapy
    • technique
      • 6 weeks of cessation from throwing
      • initiate physical therapy for flexor-pronator strengthening and improving throwing mechanics (after 6 weeks and symptoms/pain have resolved)
      • progressive return to throwing program
  • UCL anterior band ligament reconstruction
    • overview
      • various modifications of original Jobe technique exist
      • all create an anatomic reconstruction of the native ligament from medial epicondyle to ulnar sublime tubercle
        • none are stronger than native ligament
    • approach
      • muscle-splitting approach (decreases morbidity to flexor-pronator mass)
      • in-situ ulnar nerve decompression
        • transposition reserved for patients with pre-operative ulnar nerve symptoms, subluxation of ulnar nerve, and/or with ulnar nerve motor weakness 
      • UCL and joint capsule identified, ligament repaired in side-to-side fashion
    • soft tissue
      • palmaris longus autograft most common graft (gracilis autograft or allograft also options)
        • single, distal transverse incision centered over palmaris
        • tendon identified and tagged with suture, underlying median nerve protected
        • tendon followed proximally with additional incision made centered over tendon
        • confirming enough length obtained, tendon harvested and wounds closed
    • bony work and reconstruction
      • modified Jobe technique
        • two bone tunnels made in medial epicondyle of humerus 
        • single bone tunnel created by connecting two angled drill holes in ulnar sublime tubercle
          • alternatively, commercially available drill guides may be used
        • graft passed through ulnar tunnel, then graft ends through humeral tunnels
        • graft sutured to itself in figure-of-8 configuration
          • extra strands may be added if graft accommodates this
      • docking technique  
        • single bony socket made in medial epicondyle 
        • single bone tunnel created by connecting two angled drill holes in ulnar sublime tubercle
        • graft passed through ulnar tunnel, suture limbs passed through two bone punctures, graft shuttled into humeral socket 
        • graft suture ends tied over bony bridge on medial epicondyle
      • hybrid interference-screw technique
        • docking tunnel/socket made on the humerus
        • single longitudinal bone socket made into ulna with interference-screw fixation
      • cortical suspensory fixation, ex. "Endo-button" (Smith & Nephew) reconstruction
        • used on ulna to stabilize graft
    • postoperative care
      • early
        • early active wrist, elbow, and shoulder range of motion
        • incorporation of shoulder girdle, core, and hip strengthening exercises
        • strengthening exercises beginning four to six weeks post-op
      • mid-term
        • initiate a progressive throwing program at four months
        • avoid valgus stress until 4 months post-op
      • return to competitive throwing at 9-12 months post-op
  • UCL repair 
    • approach
      • as above
    • soft tissue
      • ulnar nerve in-situ release or transposition
      • ligament dissected and avulsion identified
    • bony work
      • ligament sutured and secured to either humerus or ulna with suture anchor
      • repair can be augmented with high-strength suture
    • postoperative care
      • similar to UCL reconstruction
Complications
  • Ulnar neurapraxia
    • most common, 3-26% incidence
    • treatment
      • observation as majority resolve within a few months
  • Medial antebrachial cutaneous (MABC) nerve injury
    • crosses at distal aspect of the incision
  • Fracture of ulna or medial epicondyle
    • risk factors
      • small bone bridge during tunnel placement
    • treatment
      • may require internal fixation of fracture, or switch to larger graft fixation device
  • Elbow stiffness
    • risk factors
      • heterotopic ossification
    • treatment
      • early directed therapy focusing on obtaining motion
      • HO excision around 6 months, if present
  • Inability to regain preinjury level throwing ability
    • more common following revision reconstructions
 

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Questions (22)
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(OBQ13.158) A 28-year-old professional baseball pitcher sustains a complete rupture of his ulnar collateral ligament. He is neurovascularly intact on exam. Which of the following surgical reconstruction techniques has been shown to result in the lowest complication rate and best patient outcome? Review Topic | Tested Concept

QID: 4793
1

Splitting of flexor-pronator mass, figure-of-8 graft fixation.

13%

(525/4107)

2

Splitting of flexor-pronator mass, docking graft fixation.

54%

(2217/4107)

3

Splitting of flexor-pronator mass, docking graft fixation, ulnar nerve transposition.

22%

(918/4107)

4

Detachment of flexor-pronator mass, figure-of-8 graft fixation, ulnar nerve transposition.

6%

(240/4107)

5

Detachment of flexor-pronator mass, docking graft fixation, ulnar nerve transposition.

3%

(129/4107)

L 5 B

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(OBQ12.86) A 19-year-old male complained of right elbow pain 4 months ago after pitching in a collegiate baseball game. He underwent a period of rest and forearm strengthening and now has recurrence of pain during a throwing interval program. A MRI is shown in Figure A. What is the next most appropriate step in management? Review Topic | Tested Concept

QID: 4446
FIGURES:
1

Open ECRB tendon release and removal of the diseased tendon with repair of the tendon remnant

3%

(162/5485)

2

Arthroscopic debridement of lesion and osteotochondral autograft transplant from ipsilateral knee

2%

(116/5485)

3

Excision of the diseased tendon and reattachment of the origin of the flexor-pronator muscle group to the medial epicondyle

6%

(349/5485)

4

Open reconstruction of the ligament using ipsilateral palmaris longus tendon

84%

(4589/5485)

5

Diagnostic elbow arthroscopy, removal of posteromedial olecranon osteophytes and débridement of chondromalacia

4%

(229/5485)

L 2 B

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(OBQ10.212) A 22-year-old collegiate pitcher sustains a medial collateral ligament (MCL) rupture of his throwing elbow requiring surgical reconstruction. Anatomic restoration of the MCL is desired to maximize function. Which of the following best describes the kinematics of the native MCL? Review Topic | Tested Concept

QID: 3305
1

Anterior bundle becomes tight in flexion and lax in extension

17%

(630/3729)

2

The posterior bundle demonstrates the greatest change in tension from flexion to extension

58%

(2172/3729)

3

Posterior bundle becomes lax in flexion and tight in extension

7%

(264/3729)

4

Posterior bundle is isometric

4%

(155/3729)

5

The posterior bundle is isometric, but the anterior is not

13%

(486/3729)

L 4 C

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(OBQ10.216) A 25-year-old professional baseball pitcher complains of medial elbow pain during the early acceleration phase of throwing. He has lost 10 mph on his fastball. Radiographs of the elbow are provided in Figure A. EMG studies demonstrate no entrapment of the ulnar nerve. Which of the following physical exam maneuvers will most strongly confirm the correct diagnosis? Review Topic | Tested Concept

QID: 3309
FIGURES:
1

Evaluating for pain with resisted wrist flexion

4%

(130/3222)

2

Testing for Froment's sign

1%

(38/3222)

3

Evaluating for pain with Hawkins impingement test

1%

(22/3222)

4

Evaluating for pain with moving valgus stress test

89%

(2883/3222)

5

Performing the lateral pivot shift test

4%

(130/3222)

L 1 C

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(OBQ09.105) All of the following protect the elbow from valgus loads during the throwing cycle EXCEPT? Review Topic | Tested Concept

QID: 2918
1

Flexor-pronator muscle contraction

5%

(39/821)

2

Reduced fastball velocity

9%

(70/821)

3

Increased glenohumeral internal rotation torque

59%

(482/821)

4

Forearm pronation

11%

(89/821)

5

Scapular protraction/retraction

16%

(135/821)

L 3 C

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(OBQ08.247) The greatest stress on the medial ulnar collateral ligament of the elbow occurs during which phase of throwing? Review Topic | Tested Concept

QID: 633
1

Wind-up

1%

(18/1483)

2

Early cocking

7%

(104/1483)

3

Late cocking

84%

(1246/1483)

4

Ball release

5%

(80/1483)

5

Follow through

2%

(30/1483)

L 1 B

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(OBQ08.242) Which of the following is the primary stabilizer to resist valgus stress in mid-flexion of the elbow? Review Topic | Tested Concept

QID: 628
1

Ulno-humeral articulation

3%

(32/1038)

2

Radio-capitellar articulation

5%

(47/1038)

3

Anterior oblique ligament of the medial ulnar collateral ligament

73%

(760/1038)

4

Posterior oblique ligament of the medial ulnar collateral ligament

18%

(182/1038)

5

Flexor-pronator muscle mass

1%

(10/1038)

L 2 C

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(SAE07SM.56) A professional pitcher reports pain localized to the medial aspect of his throwing elbow. History reveals that he was pitching in a playoff game and heard and felt a pop in his elbow. MRI reveals a complete ulnar-sided avulsion of the medial collateral ligament (MCL). Examination reveals valgus instability and ulnar nerve involvement. What recommendations should be made based on the patient’s desire to return to sport? Review Topic | Tested Concept

QID: 8718
1

Surgical reconstruction

81%

(196/242)

2

Rest, followed by physical therapy

1%

(3/242)

3

Splinting in 15 degrees of flexion

1%

(3/242)

4

Primary repair

14%

(34/242)

5

Arthroscopic debridement, followed by bracing in full extension for 4 weeks

1%

(2/242)

N/A E

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(OBQ07.119) During which phase of the overhead throwing cycle is a baseball pitcher most likely to rupture the medial ulnar collateral ligament complex of the elbow? Review Topic | Tested Concept

QID: 780
1

Follow-through

4%

(30/708)

2

Ball release

4%

(28/708)

3

Early acceleration

78%

(552/708)

4

Early cocking

12%

(85/708)

5

Wind-up

2%

(12/708)

L 1 A

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