Treatment method most effective in repair and prevention of reinjury of the UCL

Introduction

What is the UCL? The ulnar collateral ligament, or UCL, is the primary stabilizer of the elbow during valgus stress. It is located on the medial side of the elbow. Injuries to this ligament include partial tears, full tears, and ruptures. This injury can happen to anyone, but it is most commonly seen in overhand throwing athletes due to the amount of valgus stress being placed on the elbow due to the late cocking and early acceleration of a forceful throw. The main symptom reported is valgus instability, as well as pain, decreased velocity, and inaccuracy of throws. The first procedure to repair a torn UCL was performed by Frank Jobe MD in 1974 on Los Angeles Dodgers pitcher Tommy John. Before this successful repair, a torn UCL was considered to be career-ending. There have since been many alterations to the original procedure, as well as new methods of repair. 

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Diagnostic Methods

There are two methods of diagnosing a UCL injury. 

  • Magnetic Resonance Imaging (MRI)
    • The use of an MRI is the original method of diagnosing a UCL injury. The donut-like machine takes a picture of the elbow, and a radiologist then reviews the internal imagine to diagnose a tear. Tears are sometimes missed, as they can be full or partial. From there, an orthopedist then decides on the next option of treatment, whether it's surgery or not. 
  • Musculoskeletal Ultrasound
    • Musculoskeletal Ultrasound is a newer method of diagnosing a UCL injury. An ultrasound machine is used to view the internal structures of the elbow to then determine if there is an injury. Many clinicians may use this method to confirm the results of an MRI if the MRI pictures come back with no injury seen and the clinician feels as if that is not correct. This option is much more affordable than the MRI, however, some patients end up getting both if necessary. 

Repair Methods for Ulnar Collateral Ligament Injuries

There are a variety of methods of repair for the UCL. Most repair methods are surgical, except for one.

  • Nonsurgical Method
    • Platelet-Rich Plasma Injections
      • A series of two injections of leukocyte and platelet-rich plasma. Typically two injections are given. This repair method is recommended for older athletes who are late into their careers. This is due to them having less time to rehabilitate the injury, as well as just not having surgery, because they won't be playing for much longer anyway. 
  • Surgical Methods
    • Internal Bracing Method
      • Collagen dipped fibertape is placed over the tear. Over time your body naturally heals to it and repairs the tear. This method is good because it does not require an autograft, but rather an artificial graft. This takes away the risk of rejection of the graft. 
    • Modified Jobe Technique with Docking Method
      • This method is referred to as the "gold standard." Frank Jobe was the first surgeon to successfully repair a UCL, however, since his original procedure, there have been many alterations to his method. This method uses the original technique which requires an autograft, typically taken from the wrist or thigh. The graft is looped through multiple tunnels of the elbow (like the original procedure) but is then sutured to the humerus. On top of that, the graft is then further secured by tying a suture over a bony bridge in the elbow. 
    • Suture Augmentation Method (pictured below)
      • This method does not require a graft at all, which has been proven to be more effective than a graft. In this procedure, the tear is repaired with anchors secured on each side of the tear, then it is pulled together with sutures. It restores the normal anatomy of the elbow and does not risk complications of a graft, as well as avoids having to take the graft from somewhere else in the body. The return-to-sports rate is the most rapid with this method. 
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Post-Op Rehabilitation
  • The rehabilitation process post-operation is typically begun at the 1-week post-op mark. The first week consists of mainly range of motion exercises for the wrist and shoulder, as the elbow is still in a brace. The second week will change the angle at which the elbow is kept at, as it starts at 90 degrees. Wrist and shoulder range of motion exercises will be continued. Week 3 just adjusts the brace again. Week 4 is the beginning of the "intermediate phase." This begins the involvement of elbow range of motion and exercises, beginning very lightly. Each week after this includes more and more elbow involvement. For baseball players,  the off-mound throwing program begins. The program focuses on strengthening and flexibility. 
About the Author



Kayla Castellano is a Senior Movement Science major with a Sports Medicine concentration at Westfield State University. She began her education with the anticipation of continuing to Physician Assistant school, but quickly found a love for Oncology, and has since decided to become a Radiation Therapist after graduating. You can contact her via email at kcastellano9872@westfield.ma.edu.

References

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    22, 2020, from https://pubmed.ncbi.nlm.nih.gov/29164165/

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    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445125/

Jones, C., Beason, D., & Dugas, J. (2018, February 16). Ulnar Collateral Ligament Reconstruction Versus 
    Repair With Internal Bracing: Comparison of Cyclic Fatigue Mechanics. Retrieved October 21, 2020, 
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    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263241/

Trofa, D., Lombardi, J., Noticewala, M., & Ahmad, C. (2017, December 25). Ulnar Collateral Ligament 
    Repair With Suture Augmentation. Retrieved October 21, 2020, from 
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5852258/

Wood, N., Konin, J., & Nofsinger, C. (2010, December). Diagnosis of an ulnar collateral ligament tear 
    using musculoskeletal ultrasound in a collegiate baseball pitcher: A case report. Retrieved October 23, 
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