Ulnar Collateral Ligament Injury Presentation
Written by Chelsey Knutzen, AT, Highlands Ranch High School
The ulnar collateral ligament (UCL) can become stretched, frayed, or torn through stress. Professional pitchers have been the athletes treated most often for this problem. Javelin throwers and football, racquet sports, ice hockey, and water polo players have also been reported to injure the UCL. A fall on an outstretched arm can also lead to UCL rupture (often with elbow dislocation).
The bones of the elbow are the humerus (the upper arm bone), the ulna (the longer bone of the forearm, on the opposite side of the thumb), and the radius (the shorter bone of the forearm on the same side as the thumb).
The elbow itself is essentially a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius (the radial head) meets the humerus. This joint is complicated because the radius must rotate so that you can turn your hand palm up and palm down. At the same time, it must slide against the end of the humerus as the elbow bends and straightens.
The joint is even more complex because the radius has to slide against the ulna as it rotates the wrist as well. As a result, the end of the radius at the elbow is shaped like a smooth knob with a cup at the end to fit on the end of the humerus. The edges are also smooth where it glides against the ulna.
In the elbow, two of the most important ligaments are the ulnar collateral ligament (UCL) and the lateral collateral ligament. The UCL is also known as the medial collateral ligament. The ulnar collateral ligament is on the medial side of the elbow (the side of that's next to the body), and the lateral collateral ligament is on the outside. The ulnar collateral ligament is a thick band of ligamentous tissue that forms a triangular shape along the medial elbow. It has an anterior bundle, posterior bundle, and a thinner, transverse ligament.
Together these two ligaments, the ulnar (or medial) collateral and the lateral collateral, connect the humerus to the ulna and keep it tightly in place as it slides through the groove at the end of the humerus. These ligaments are the main source of stability for the elbow. They can be torn when there is an injury or dislocation of the elbow. If they do not heal correctly, the elbow can be too loose or unstable. The ulnar collateral ligament can also be damaged by overuse and repetitive stress, such as the throwing motion.
Athlete is a 16 year-old who participates in football. During a football game, the athlete was on defense and was in the process of tackling an opponent with an outstretched arm. One of the athlete’s teammates came in from the left side; hitting the athlete’s left arm, creating a valgus force on the athlete’s elbow.
Upon first evaluation, the athlete presented with tenderness over the medial side of the elbow (the inside). There was minimal swelling and no discoloration. Special tests were performed to confirm diagnosis. Valgus stress tests are done at the elbow to test for joint stability. The examiner places force toward the inside of the elbow as the joint is moved from a position of slight flexion into full extension. Too much motion or opening of the joint at the medial joint line, called gapping, may be observed or felt by palpation. The examiner may also feel the crepitation (popping, crunching) as the joint moves. The special test showed that there was some slight laxity in the joint, but the ulnar collateral ligament is not torn.
For the treatment of this injury, there are a wide range of options for recovery. For this case, cryotherapy was the first modality used to prevent any excess swelling. Also maintaining the range of motion was a treatment goal. Once the first 24 hours had passed, a combination of ultrasound and electrical stimulation (TENS) were introduced to provide a slight heating affect and to help with the pain levels and aid in muscle recovery, relaxation, and rehabilitation. There was also a stretching and strengthening program implemented. The stretching aspect focused mostly on the forearm flexor muscles, while the strengthening was aimed at the whole arm complex, even up into the shoulder. Once the athlete had minimal pain and had full range of motion, a brace was used during practice and games to protect and prevent further damage to the ulnar collateral ligament. Therapy and rehab were continued through the remainder of the season to ensure the athlete was returned to full strength.
UCL sprains have a wide range of severity, varying from a slight sprain to a complete tear. If there is pain on the inside of the elbow, that maybe the first sign that there is an issue with the UCL. Seeing an orthopedic doctor will help to evaluate the severity. They may request an MRI to see how much damage there is to the ligament. After determining the severity, the doctor will recommend physical therapy and a decrease in activities that may stress or further injure the ligament. If it is completely torn, it will oftentimes require surgery. In this injury case, the damage was very mild, and there was minimal laxity in the elbow. The sports that are most prone to this injury are baseball, football, lacrosse, basketball, tennis, and volleyball.