Elbow Ulnar Collateral Ligament (UCL)
The Ulnar Collateral Ligament (UCL) is an ligament complex on the medial (inside) part of the elbow, and is very important for elbow stability. It has become very recognized recently because of its role in baseball pitchers, the first being performed on Tommy John, for which the surgery has now popularly named. However, this ligament can be injured in any throwing athlete, as well as wrestlers, martial artists, and anyone suffering a dislocated elbow.
In throwing athletes, pain on the inside of the elbow and even gross instability can be felt especially in the early cocking phase of the throwing motion. Pitchers may notice a loss of velocity and/or command of the pitch. Those with the most severe versions can feel their elbow being unstable and at times can actually feel their elbow feel out of place or partially dislocated. Over time, untreated UCL tears can lead to bone spurs and osteoarthritis.
Numbness and tingling is commonly present in the ulnar nerve, which is responsible for sensation into the little finger and part of the ring finger. If the nerve symptoms progress, it can also lead to strength and coordination loss of the little muscles in the hand.
On physical examination, localized tenderness over the UCL and a test called the "milking maneuver" as well as the "moving valgus stress test" are usually positive and indicative of a UCL tear.
X-rays are normally ordered to rule out a fracture or other diagnoses. An MRI is often ordered to determine the presence or severity of the tear, as well as to rule out other diagnoses. Rarely, the diagnosis may not be fully elucidated from the physical exam and radiologic studies, in which case a diagnostic scope is sometimes done to confirm the diagnosis. This is performed at the same time as the repair/reconstruction so that separate anesthesia is not required.
UCL tears that are partial can be treated with non-operative treatment first, often with a hinged brace for at least 6 weeks. The option of adding biologic stem cell therapy such as Platelet Rich Plasma (PRP) may be discussed to help accelerate and improve upon the healing response.
Surgery is recommended on a case by case basis, but is usually indicated for complete tears of the UCL especially in the dominant arm of a throwing athlete. It may also be recommended in those patients who feel gross instability, have partial tears or pain that have failed nonoperative treatment.
Elbow surgery is an area requiring special expertise in order to master because some elbow surgery is typically performed by hand surgeons, and others by sports surgeons, yet neither of them typically do a large quantity of elbow surgery. Dr. Steven Lee is uniquely fellowship trained in both hand/upper extremity surgery as well as sports medicine, and has is one of the most experienced orthopaedic surgeons for elbow surgery in NYC. This particular operation happens to also be one that Dr Lee has a special interest in and has been pioneering innovative newer and stronger techniques compared to what is currently being done. He also regularly instructs courses teaching other orthopaedic surgeons how to perform this operation. Learn about scheduling surgery.
All surgical patients are immediately immobilized in a non-removable splint from above the level of the elbow to the hand for 7-10 days following surgery. During this time, patients are encouraged to elevate their hand above their heart, keep their dressings clean and dry, and to move their fingers. Patients are allowed to use their fingers to text and type, but not to lift anything heavier than a cup of coffee or that which causes them more than a 2/10 pain level.
Patients will then be transitioned into a locked elbow brace and wrist immobilizer for 3 weeks. After this, the patient will be required to start occupational therapy (OT) to regain back strength and mobility. While many patients will be surprisingly functional 6 weeks out from surgery, it often takes up to 4-6 months to be cleared for all activities including sports. For baseball pitchers, full recovery can take a year or longer.
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.