Ulnar Collateral Ligament

RehabilitationBy: Michael Cox

Bony Anatomy Humerous: Medial epicondyle- trochlea which serves as the axis of rotation for ulna on the humeorusLateral epicondyle- capitellum which serves as the axis of rotation for the radiusRadial fossa- accepts radial head during flxCoranoid fossa- accepts coranoid process during flxOlecronon fossa- accepts olecronon during ext

Ulna:Olecronon processCoranoid process

Radius:Radial headRadial tuberosity

Bony Anatomy Humeroulnar joint

Hinge jointStrong and stableAllows for flexion and extension

Humeroradial jointModified ball and socket joint

Proximal radioulnar jointAllows for pronation and supination

Ligamentous support Ulnar Collateral Ligament:

Resists valgus loads 3 bundles Anterior- taut throughout full ROM, primary restraint against valgus stress Transverse- provides little medial support Posterior- taut in flexion beyond 60 degrees

Lateral Collateral Ligament: Resists varus forces Composed of radial collateral ligament, lateral ulnar collateral ligament, annular and accessory ligament

Annular Ligament:Encases radial headDoesn’t let ulna and radius move into flexion and extension independently

Musculature Flexors:

Biceps brachii, brachioradialis, brachialis Extensors:

Triceps brachii, anconeus Forearm Pronators:

Pronator teres, pronator quadratus Forearm Supinators:

Supinator, assisted by biceps and brachioradialis

Mechanism of Injury Most ulnar collateral ligament injuries

occur in overhead throwing athletes This due to the extreme valgus stress

placed on the elbow throughout the throwing motion Acutely the UCL can also be injured

with a lateral blow to the elbow

Clinical Evaluation The patient will complain of pain on the medial aspect of the elbow

that increases with motion Tingling or numbness may be present due to the tensile force placed

on the ulnar nerve Point tender from the along the medial epicondyle Some swelling may be noticeable Positive valgus stress test

Acute treatment Refer patient for a MRI Restrict any throwing movements

Can sling if more comfortable Modalities can be used to help reduce pain and

inflammation such as ice and electrical stimulation for gate theory pain control

Surgical Patients If surgery Is needed- “Tommy John”- usually uses

palmaris longus tendon as a graft to replace UCL Immobilization wit the arm at 90 degrees of flexion for

10-14 days At this time wrist and finger ROM exercises can be

started Gripping exercises with puddy Shoulder ROM

Beginning RehabilitationWeeks 0-3

Goals:Decrease pain and inflammationImprove ROMRetard atrophy

Early Rehab- Passive ROM

Passive extension with dumbbell hanging off table (towel under joint)2 lbs.for 5-7 minutes (long duration, low intensity stretch)

Pulley flexion and extension3 sets- 10 repetitions

Clinician passive ROM

QuickTime™ and aTIFF (LZW) decompressor

are needed to see this picture.

Early Rehab- Active ROM

Wand exercises: 3 sets- 10 repetitionsflexion extensionpronation supination

Wrist ROM

Active ROMflexion, extension, pronation, supination

Early Rehab- Decreasing Pain

Joint Mobilizations- grade I and II oscillations- posterior glide

Ice Electrical Stim

- gate theory

Early Rehab- Strengthening

Isometrics flexion, extension, pronation, supination

• 3 sets of 10 repetitions holding contractions for about 5-10 seconds

• Refrain from internal and external rotation due to the valgus stress it places on the UCL

Intermediate Rehabilitation

Weeks 4-8

Goals:Improving strength and enduranceReestablishing neuromuscular controlMaintain full ROM

Criteria: Near total ROM with minimal pain

Intermediate RehabilitationIsotonic exercises

Flexionextensionpronationsupination

3 sets- 10 repetitionsStarting at 2lb dumbbell and progressing as strength increases

Wrist isotonic exercises

Rhythmic Stabilizationclinician assistedswiss ball4 sets- 20s

Intermediate RehabilitationDiagonal PNF patterns

Body Blade

straight arm and at 90

Moderate Rehabilitation

Weeks 9-13Goals: Advanced strengthening phase Increase total arm strength, power, endurance,

and neuromuscular control Prepare patient for functional return to play

activities

Criteria: Full non painful ROM Strength close to 70% of uninvolved limb

Moderate Rehabilitation

Eccentric training Theraband- biceps and triceps

Moderate Rehabilitation

Throwers 10- total arm strength Dumbbell abduction Prone dumbbell abduction Prone extension Internal rotation External rotation Theraband shoulder flexion and extension Progressive pushups Medicine ball punches- serratus anterior Diagonal D2 PNF Wrist flexion, extension, pronation, supination

Moderate Rehabilitation

PlyometricsMed ball throws one handSoccer throwChest passSide to side

Plyometric press up

Moderate Rehabilitation

Progressive medicine ball plyometricsIncreased soccer throws

8-10 reps

Side hits2 sets- 30 seconds

External rotation throws3 sets- 10 reps

Final RehabilitationWeeks 14-26

Goal: Progressive functional drills Continue to increase strength, endurance,

power Return to play

Criteria: Full ROM with no pain Full strength

Final Rehabilitation Throwing program

Increase in distance and amount of throws Enough rest time in-between session: 2-3 days

Batting practice Tees Soft toss Slow pitching Against a pitcher

Return To PlayFull ROMFull strengthNo direct pain with throwing or hittingNormal cardiovascular endurancePhysiologically ready

ArticleEmphasizes maintaining full elbow

extension earlyImportant to strengthen elbow and

wrist flexors, and pronators- importance in follow through phase

Rotator cuff strengthProgressive and essential

rehabilitation program

Summary Elbow joint has strong bony support as well as

ligamentous and capsular support Mechanism of injury is usually repetitive valgus stress Progressive rehab with certain criteria that must be met

before moving on Avoid internal and external rotation early in rehab due

to valgus stress it places on elbow Maintain cardiovascular endurance and core strength

throughout rehab Flexibility Continue strengthening once back to full participation to

decrease risk of re-injury

Questions

??????????