Ulnar Collateral Ligament (UCL) Injury

Ulnar Collateral Ligament (UCL) Injury

Injury to the UCL (ulnar collateral ligament) of the elbow has most commonly been associated with baseball pitchers and has gained significant public attention over the years, and made somewhat famous as "the Tommy John Surgery."

The UCL is a small ligament on the inner portion of the elbow that provides stability to resist valgus force (angulation) at the elbow joint. It can be injured acutely in traumatic elbow injuries such as elbow dislocations or injuries that commonly occur in gymnastics, wrestling and falls from a height. These are often abrupt injuries and many times result in a complete tear or rupture of the ligament.

The more common mechanism of injury occurs over a long period of time with gradual stretching of the ligament or degradation of the tissue from repeated significant forces across the elbow joint, such as occurs with elite level baseball pitchers. These situations typically result in a broader area of damage to the ligament and present with typically a more gradual onset of pain and dysfunction. These differences are key to the understanding of how the injury occurs, the likely overall health of the ligament, and ultimately the type of treatment that should be undertaken.

The diagnosis of a tear in the UCL is made based on the presenting symptoms, a very careful and specific physical examination, X-rays, and an MRI. Often the physical examination will be augmented with the use of fluoroscopy which is a continuous low-level X-ray that can demonstrate excessive motion in the elbow joint due to the injury. This is typically compared to the motion of the other elbow and can be measured. The MRI is used to identify the location and severity of the tear and evaluate the overall health of the ligament. This is very important for planing treatment.

The treatment for an elbow UCL injury is based upon the type of activity of the patient or type of sport or even the specific position, as well as the mechanism of injury, location of the tear, and the integrity of the remaining ligament. Most athletes that have an acute injury to this ligament and do not routinely participate in certain sports (gymnastics or pitching in baseball) will heal the injury and can return to activity without needing surgery. Some minor amount of residual laxity may persist, but this is typically insignificant and not limiting. However, in the setting of an athlete that will place repeated stress on this specific aspect of the elbow, then that athlete may not be able to return effectively without having it surgically stabilized.

The specific type of surgery (if needed) falls into 1 of 2 broad categories: repair or replace (or reconstruct). The direct repair is typically reserved for athletes with acute single injuries to the elbow where the ligament is largely intact and healthy but has been torn off of the bone. However, those more chronic overuse forms of injury are best treated with a ligament reconstruction. This has been referred to commonly as "the Tommy John Procedure." The specifics of the procedure are variable based on surgeon training and preference, but overall they are very successful. As a reconstruction, this involves using other tissue to re-create a new ligament, which can be tissue harvested from the patients own body in another location (known as autograft) or from a human donor tissue bank (known as allograft). Both are very successful, and each carries positive and negative attributes. The decision upon which graft type to use is ultimately a decision to be made in discussion with your surgeon.

The rehabilitation process after the surgery requires approximately 4 months of gradual increase in motion and strengthening before beginning the process of returning to sports.