Ulnar collateral ligament ulcers may occur during certain activities such as baseball pitching overhead. Acute or chronic disturbance and/or attenuation of the collateral ulnar collateral often results in medial elbow pain, valgus instability, neurological deficiency, and throwing performance disorders. There is a choice of non-surgical and surgical treatment.
Video Ulnar collateral ligament injury of the elbow
Underlying anatomy
The ulnar collateral ligament (UCL, also known as the medial collateral ligament) is located on the medial side of the elbow. The UCL complex consists of three ligaments: anterior oblique ligament, posterior oblique and transverse. The anterior oblique ligament (AOL) attaches from the lower surface of the medial epicondyle to the medial ulnar surface slightly below the coronoid process. This is the sturdiest of the three parts in UCL. AOL acts as the ultimate restraint against valgus stress on the elbow during flexion and extension. The posterior oblique originates from the medial epicondyle and inserts along the medial mid-semilunar notch portion. This applies more stable to valgus stress when the elbow is flexed rather than extended. The transverse ligaments connect to the medial inferior medial ulna process to the medial end of olecranon. Because it is connected to the same bone and not across the elbow joint, the transverse ligament has no contribution to the stability of the joint.
Maps Ulnar collateral ligament injury of the elbow
Classification
Slow and chronic ulnar ligament deterioration can be caused by repetitive stress acting on the ulna. At first, the pain can be intolerable and can worsen to a level where it can end an athlete's career. The recurrent stress placed on the ulna causes micro tears in the ligaments to result in loss of structural integrity over time. Acute rupture is less common than slow injury damage. Acute rupture occurs during a collision when the elbow is in a position of flexion as in a wrestling match or tackle in football. Ulnar littance distributes more than fifty percent of medial support of the elbow. This can cause injury of the ulnar collar ligament or a dislocated elbow which causes severe damage to the elbow and radioulnar joint.
Cause
UCL is important because it stabilizes the elbows so as not to be kidnapped. If an intense or recurrent valgus stress attack occurs on UCL, an injury is most likely to occur. Damage to the ulnar collateral ligament is common among baseball pitchers and javelin throws due to similar throwing motions. Doctors believe repetitive movements, especially throwing baseballs, cause teenage UCL injuries. Furthermore, doctors have stated that if a teenager throws more than 85 tosses for 8 months or more in a year, or discards when fatigue, the adolescent has a significantly higher risk of succumbing to UCL surgery. Gridiron football, racket sports, ice hockey, and water polo players have also been treated for ulnar ligament damage. Special overhead movements such as those that occur during baseball pitching, tennis serving or volleyball spikes increase the risk of UCL injury. During the pitching inclination phase, the shoulders are horizontally kidnapped, rotated externally and the elbows folded. There is little pressure on the UCL in this position but it increases when the more external shoulders are rotated. The larger the pressure the more UCL stretches, causing tension. During the upper throwing movement, the valgus pressure on the medial elbow occurs as the arm tilts and accelerates. Valgus voltage initiation occurs at the end of the arm-cocking phase. At the time of the transition from arm cocking to arm acceleration, the shoulders rotate strong internally, the forearms are near full supination, and the elbows flex from 90 ° to about 125 °. From the final throw to the ball release, the elbow quickly extends from about 125 Â ° to 25 Â ° on the release of the ball. This leads to tremendous valgus pressure and tensile strain on UCL. Injuries to the ulnar collateral ligament are believed to result from poor throwing mechanics, excessive use, high throwing speeds, and certain types of throws, such as curveballs. Poor mechanics along with repetitions of this high overhead movement can cause irritation, tear-up or UCL rupture. Injuries to the Lateral Ulnar Collateral in a baseball player are rarely due to a one-time, traumatic event. Rather, they are more commonly caused by small chronic tears that accumulate over time.
Epidemiology
According to the International Classification of Diseases, 9th Revision, Clinical Modification, ICD-9-CM, in 2008 the US recorded the diagonsis code for UCL injury as 841.1: Collateral sprain ulnar ligament. There are a total of 336 UCL injuries. In total disposal, separated by age group: 18 to 44 years; 165 people (49.17%). 45 to 64 years; 91 (27.08%). Ages 65 to 84, 65 (19.35%) showed that ulnar collateral ligament injury was more common in men than women. There were 213 men compared with 123 women with ulnar collateral ligament injury. Most of these injuries are also paid through private insurance (170: 50.63%) and Medicare (70: 20.85%). The approximate average cost for the operation also known as Tommy John's operation is $ 21,563.
Diagnosis
In most cases, a doctor will diagnose an ulnar collateral ligament injury using a patient's medical history and a physical examination that includes a valgus stress test. Valgus voltage tests are performed on both arms and a positive test is indicated by pain in the affected arm that is absent on the side that is not involved. Doctors often use imaging techniques such as ultrasound, x-rays and magnetic resonance imaging or arthroscopic surgery to help make the right diagnosis.
Signs and symptoms
Pain along the inside of the elbow is a major symptom of this condition. The report of the throwing athlete occurs most often during the throwing acceleration phase. Closing hands and clenching fists have also been shown to reproduce painful symptoms. This injury is often associated with a sharp "pop" experience at the elbow, followed by pain during a single throw. In addition, swelling and bruising on the elbow, loss of elbow gestures, and sudden drop of throwing velocity are common symptoms of UCL injury. If the injury is less severe, the pain can be minimal with total rest.
Treatment
UCL injury may or may not require surgery. Non-surgical treatment will mainly focus on strengthening the elbow joint to regain strength and stability. First, the RICE program (Rest, ice, compression, elevation) is usually combined with NSAIDS (non-steroidal anti-inflammatory drugs) to help reduce pain and swelling. When the swelling has subsided, individual exercises or physical therapy may be prescribed to strengthen the muscles around the elbow joint to compensate for tearing at UCL. These may include biceps curls, pronation and supine forearm, and grip strengthening exercises, performed with low resistance and moderate repetition of no more than three times a week.
Surgical treatment can help restore the ability to make excessive throwing movements most commonly associated with UCL injuries. Reconstructive surgery, commonly known as Tommy John's surgery, was first performed by Dr. Frank Jobe in 1974 and has been modified several times over the past 30 years. Surgery involves the autograft of the longus tendon palmaris (mostly seen as an accessory tendon) or tissue allograft of a corpse or donor. The new tendon is fitted with a drilling hole in the medial epiconducts of the humerus and the ulna noble tubercle and binding the tendons through them in the number eight. Patient can start physical therapy soon after. It usually takes about 15 months after surgery for standard rehabilitation. In a study conducted by Dr. Frederick Azar, 78 Tommy John operations performed and analyzed after the operation. Of the 78 patients, 8 of them (8.8%) reported complications. Two patients had superficial infections that were resolved with oral antibiotics, two patients reported experiencing shortness of tenderness at the site of operation, and one had a superficial wound infections on an elbow incision that was resolved with oral antibiotics. One patient suffered postoperative ulnar nerve damage. Two patients suffered damage to the posteromedial portion of olecranon and had to undergo surgery.
Recent studies have shown that MLB pitchers who underwent Tommy John's surgery returned to the field in MLB 83% of the time and only 3% failed to return to the field in the MLB or minor league.
Recently, there has been an increase recorded in Tommy John's operations. This increase is associated with a false perception that surgery improves UCL joint stability. Many athletes believe in this false perception and cause them to lie about their symptoms in the hope of undergoing surgery. To combat these rumors, doctors are motivated to educate the public that Tommy John's operation is only for those who have severe UCL injuries. Surgery will have an insignificant effect if the patient does not suffer severe UCL injury.
The selected tendon is then woven in the pattern of the number eight through the humerus and ulna, the first hole drilled in the bone. After the surgery occurs, rehabilitation takes place and usually takes about a year because the tendon takes time to turn into a ligament.
References
Source of the article : Wikipedia
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