Bone & Joint Expert Care

Ulnar collateral ligament injury

What is an Ulnar Collateral Ligament Injury of the Elbow?

Ulnar collateral ligament injury of the elbow is a sprain (tear) of one of the ligaments on the inner side of the elbow. The ulnar collateral ligament (UCL) is a structure that helps keep the normal relationship of the humerus (arm bone) and the ulna (one of the forearm bones). This ligament is injured in throwing types of sports or after elbow dislocation or surgery. It may occur as a sudden tear or may gradually stretch out over time with repetitive injury. This ligament is rarely stressed in daily activities. It prevents the elbow from gapping apart on the inner side. When torn, this ligament usually does not heal or may heal in a lengthened position (loose).

Sprains are classified into three grades. In a first-degree sprain, the ligament is not lengthened but is painful. With a second-degree sprain, the ligament is stretched but still functions. With a third-degree sprain, the ligament is torn and does not function.

How does ulnar collateral ligament injury occur?

A force that exceeds the strength of the ligament causes ulnar collateral ligament injury. This injury usually is the result of throwing repetitively or particularly hard. It may occur with an elbow dislocation or because of surgery.

What increases the risk?

Most injuries to the UCL occur in the arms of overhead throwers, particularly baseball pitchers. The injury usually occurs because of repetitive stresses in which the ligament ultimately compromised. Other risk factors include:

• Contact sports (football, rugby) and sports in which falling on an outstretched hand results in an elbow dislocation
• Throwing sports, such as baseball and javelin
• Overhead sports, such as volleyball and tennis
• Poor physical conditioning (strength and flexibility)
• Improper throwing mechanics

What are the symptoms of ulnar collateral ligament injury?

• Pain and tenderness on the inner side of the elbow, especially when trying to throw
• A pop, tearing or pulling sensation noted at the time of injury
• Swelling and bruising (after 24 hours) at the site of injury at the inner elbow and upper forearm if there is an acute tear
• Inability to throw at full speed; loss of ball control
• Elbow stiffness; inability to straighten the elbow
• Numbness or tingling in the ring and little fingers and hand
• Clumsiness and weakness of hand grip

How is ulnar collateral ligament injury diagnosed?

Pain over the medial aspect of the elbow, tenderness directly over the course of the UCL and special physical exam tests that reproduce the stress over the ligament are all helpful in confirming the diagnosis. The special physical exam tests include the “moving valgus stress test,” in which a force is applied to elbow as it is put through a range of motion. This may be the most sensitive and specific physical exam test.

Are there any special tests?

An MRI is the best test for visualizing the soft tissue structures of the elbow. When Gadolineum dye is instilled into the elbow prior to the MRI, small tears on the underside (deep portion) of the ligament can be detected, which may otherwise go unrecognized.

How is ulnar collateral ligament injury treated?

A mild injury may resolve on its own.

Non-operative treatment is indicated for most patients, who are able to successfully resume all pre-injury activities.

Non-operative treatment: Initial treatment consists of medications and ice to relieve pain and reduce the swelling of the elbow. You must stop participating in the sport that caused the injury. Occasionally a splint, brace or cast may be recommended while the acute phase subsides.

Medication may include:

• Non-steroidal anti-inflammatory medications, such as aspirin and ibuprofen (do not take within seven days before surgery), or other minor pain relievers, such as acetaminophen, are often recommended. Take these as directed by your physician. Contact your physician immediately if any bleeding, stomach upset, or signs of an allergic reaction occur.
• Your physician may prescribe stronger pain relievers as necessary. Use only as directed.

Operative treatment is usually reserved for the small number of patients with complete traumatic injuries or those with persistent pain and impairment and evidence of a compromised ligament. This is most common in baseball pitchers.

“Tommy John” procedure

For those who have an acute rupture of the ligament or those who have failed therapy and wish to continue throwing competitively, surgical reconstruction (rebuilding the ligament using other tissue) is usually recommended. This procedure is known as the “Tommy John” procedure, named for the player whose career was saved when the ligament was reconstructed by Dr. Frank Jobe.

The ligament reconstruction can be performed using a variety of soft tissue grafts obtained from the patient, but is most commonly carried out using the palmaris longus tendon from the forearm. Because this tendon provides biomechanical characteristics that are similar to those of the native ligament, and because there are no consequences from its absence, it makes an ideal ligament substitute. Some patients do not have a palmaris longus tendon and therefore require an alternative graft for reconstruction, such as one of the toe extensors.

What are treatment complications?

Possible complications of non-operative treatment include:

• Inability to return to previous level of throwing

• Frequent recurrence of symptoms, such as an inability to throw at full speed or distance, pain with throwing, and loss of ball control, especially if activity is resumed too soon after injury

• Injury to other structures of the elbow, including the cartilage of the outer elbow; loose body formation; injury to the ulnar nerve of the hand; medial epicondylitis and strain of the muscle-tendon of the muscles that bend the wrist

• Injury to articular cartilage, resulting in arthritis of the elbow

• Elbow stiffness (loss of elbow motion)

• Ulnar nerve symptoms

Possible complications of operative treatment include:

• Surgical complications not specifically associated with this procedure, such as pain, bleeding (uncommon), infection (<1%), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity

Complications specific to surgical treatment of this condition:

• Failure to restore normal stability
• Inability to return to previous level of activity (~10-20 percent failure rate)
• Ulnar nerve injury
• Irritation of cutaneous (skin) branches related to harvesting of palmaris longus tendon graft
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When can I return to my sport or activity?

• The UCL usually does not heal sufficiently on its own with non-operative treatment. To return to throwing, surgery is often necessary. Return to sports after injury without surgery may take three to six months and may take nine to 18 months following surgery.

• Rehabilitation to improve strength endurance and proper throwing mechanics is initiated. This may be carried out at home, although usually referral to a physical therapist or athletic trainer is recommended.

How can an ulnar collateral ligament injury of the elbow be prevented?

• Appropriately warm up and stretch before practice and competition
• Maintain appropriate conditioning:
  • Arm, forearm and wrist flexibility
  • Muscle strength and endurance
• Use proper protective technique when falling and throwing
• Functional braces may be effective in preventing injury, especially re-injury, in contact sports