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UCL Treatment

The Challenge in Treatment of UCL

QuestionAnswer
What population are UCL injuries common with? Overhead athletes
UCL Injury from Football Conservative tx Different kinematics of throwing fb vs. bob Weight of fb Slower throwing velocity
UCL Elbow endures tremendous stress during OH throwing Forces approach ultimate failure load of UCL with every throw
Acceleration Phase of Throwing Begins in flexion b/t 90 to 120
Baseball Pitching vs. Softball Pitching vs. Tennis Serve Elbow Extension in bsb & tennis serve Elbow flexion & underhand in sb, much slower throwing velocity
4 Stages of Ligament Pathology 1. Edema 2. Scarring & disassociation of ligament fibers 3. Calcification 4. Ossification
Differential Diagnoses Arthritis; Cervical radiculopathy; Chondromalacia- pn lateral b/t radial head/capit.; Cubital tunnel syndrome; Fibrosis; Loose bodies- start lateral, pn could be anywhere
More Differential Diagnoses Olecranon/coronoid impingement; Osteophytes; Tardy ulnar n. palsy; Ulnar trochlear synovitis
Primary Pathologic Tissue UCL complex Result of repetitive valgus overload leading to recurrent microtrauma, attenuation & eventual rupture
Etiology & Epidemiology 50% throwing athletes rupture UCL in sudden catastrophic event Almost all had pain & tenderness for months/year about medial elbow associated with throwing
Physical Exam Hx of fall on outstretched arm causing valgus thrust; Audible "pop"; Diffuse tenderness around medial elbow; +/- ulnar paresis (swelling/inflam) Valgus stress- demo instability Usu. + Tinel's sign over cubital tunnel
Valgus Extension Overload Syndrome Posterior pain during acceleration Tenderness at posterior medial joint line Posteromedial osteophyte Too much posteromedial olecranon resected leads to instability
Why should x-rays be taken? To r/o other causes of elbow pain Epitrochlear osteophytes, Epicondylar fx's; Posterior olecranon fossa loose bodies; Lig calcification; Capitellar lesions
Valgus Stress Radiograph Document jt opening/ligamentous laxity Significant asymmetry may be seen in traumatic elbow injuries such as dislocations; Throwers may demo more subtle differences
Gravity Stress Radiograph Common for dominant elbow to have loss of flexion as compared to non-dominant elbow if pt. is OH athlete that throws often
Athrography Not indicated & not useful Probably only good for acute event
MRI with Contrast Image of choice Can generate false positives due to relatively small size of UCL & dye leaking with chronic injury
Immediate Motion Phase Weeks 0-2
Goals of Immediate Motion Phase Increase ROM; Promote healing of UCL; Retard mm atrophy; Decrease pain & inflammation
Ex's in Immediate Motion Phase Isometrics wrist/hand Shoulder strengthening EXCEPT ER/IR Ice Compression
Intermediate Phase Weeks 3-6
Goals of Intermediate Phase Increase ROM Improve strength & endurance Decrease pain & inflammation Promote stability
Ex's in Intermediate Phase ROM: Gradually increase 0-135 (10 deg/week) Wrist curls, wrist extensions, Pron/supination, Bis/Tris DB: ER, Deltoid, Supra, Rhomboids, IR's Rhythmic Stabs Ice & compression
Advanced Phase Week 6/7 to 12/14
Criteria to Progress- Advanced Phase Full ROM No pain or tenderness No increase in laxity Strength of 4/5 of flexors/extensors *Remember, dominant elbow may have less ROM than non-dom
Goals of Advanced Phase Increase strength, power, & endurance Improve neuromm control Initiate high-speed exercise drills
Ex's in Advanced Phase Initiate tubing shoulder ex's Throwers 10 Bis/tris Supination/pronation Wrist ext/flex Plyo throwing drills
Return to Activity Phase Weeks 12/14
Criteria to Progress to Return to Throwing Full non-painful ROM No increased laxity Isokinetic test fulfills criteria Satisfactory clinical exam
Ex's in Return to Activity Phase Interval throwing Throwers 10 Continue plyos
What constitutes a satisfactory clinical exam? Full ROM/MMT No pain- palpation, stress testing, end range No swelling/effusion Full ssn Everything "well"
Tommy John Surgery Anterior bundle is primary focus of MCL reconstruction Use of either: Ipsilateral palmaris longus; Gracilis; Semitendinosis; Plantaris tendon
Highlights of Post-Op Rehab Emphasis on early controlled ROM to avoid excessive stretching of reconstruciton Encourage use of brace to avoid accidental valgus stress Passive stretching should be AVOIDED
Phase I: Immediate Post-Op Phase Weeks 0-3
Phase I Goals Protect healing tissue Decrease pain/inflammation Retard muscle atrophy
Post-Op Week 1 Posterior splint at 90 deg elbow flexion Wrist AROM ext/flex Elbow compression dressing (2-3 days) Cryotherapy
Post Op Week 1 Ex's Gripping Wrist ROM Shoulder isometrics (except ER/IR?) Biceps isometrics
Post Op Week 2 Functional brace (set 30-100 deg) Initiate wrist, elbow flex/ext isometrics
Post Op Week 3 Advance brace to 110 deg Gradually incrase ROM 5 deg ext & 10 deg flex per week
Phase 2: Intermediate Phase Weeks 4-8
Goals of Phase 2 Gradual increase in ROM Promote healing of repaired tissue Regain & improve muscular strength
Post Op Week 4 Functional brace set 10-120 deg Begin light resistance ex's for arm (1 lb)- wrist flex/ext, pro/sup, elbow flex/ext
Post Op Week 4 Progress shoulder program Emphasize RTC strengthening (avoid ER till week 6)
Post Op Week 4 Once steri-strips removed begin progression of scar de-sensitizatoin & mobility program
Post Op Week 6 Functional brace set 0-130 deg; AROM 0-145 without brace Progress elbow strengthening ex's Initiate shoulder ER strength ex's Progress shoulder program
Phase 3: Advanced Strengthening Phase Weeks 9-13
Goals of Phase 3 Increase strength, power, endurance Maintain full elbow ROM Gradually initiate sporting activities
Post Op Week 9 Initiate eccentric elbow flex/ext Continue isotonic program (forearm/wrist) Continue shoulder program: throwers 10 Manual resistance PNF diagonals Initiate plyos
Post Op Week 11 Continue all ex's Begin light sporting activities, but not throwing Don't usually throw till week 16
Phase IV: Return to Activity Phase Goals Continue increasing strength, power, endurance of UE Gradual return to sport activities
Post Op Week 14 Initiate interval throwing program-might wait until wk 16 though Continue strength program Emphasize elbow & wrist strength & flexibility ex's
Post-Op Weeks 22-26 Return to competitive throwing
Created by: 1190550002