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UCL Treatment
The Challenge in Treatment of UCL
| Question | Answer |
|---|---|
| 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 |
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1190550002
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