Elbow Ligament Injuries in Athletes:

Steven Klepps, MD Ortho Montana

Ulnar Collateral Ligament (UCL) Injuries This is known as the Tommy John ligament and has become much more commonly torn or at least more recognized over the last 20 years. Prior to this, it was really only recognized and treated in professional athletes. However, the injury is now increasingly diagnosed in high school, college, and minor league athletes. Although it is most commonly seen in baseball players especially pitchers, these are also seen in javelin throwers, quarterbacks, and other overhead throwers. Patients can partially tear this ligament which is very common in the younger athlete and can be treated with time, rest, and rehab. Although it can take up to 4 months, most athletes will get better and return to play. However, in patients who have completely torn the ligament or fail conservative treatment, surgery is often required prior to return to sport. This generally requires replacing the ligament with a graft from the forearm or knee and therefore takes over a year to completely recover, but most patients do well with the surgery. There has been some recent literature to suggest that this ligament can be repaired with an ‘internal splint’ and not replaced in certain tear patterns which can lead to much a quicker recovery. We will see how the results turn out over the next few years to see which patients are best treated with repair vs. reconstruction. Because the UCL is only necessary for throwing, depending on the timing, some athletes will also choose to not fix it and decide to end their career especially in the last year of college, legion ball, minor leagues, etc…, as it is a major surgery to undergo and subsequently rehab. Therefore, appropriate counseling is necessary for this injury before going straight to surgery.

Lateral Ulnar Collateral Ligament (LUCL) injuries

This ligament is on the opposite side of the elbow as the UCL. This ligament is injured more in traumatic injuries such as elbow dislocations and can be quite disabling. As opposed to the UCL which primarily only affect throwing, the LUCL affects daily activity. Therefore, if it is torn and does not heal well, this often requires surgery similar to the Tommy John surgery in that the ligament is replaced with a tendon from the wrist or knee. As stated, these often form in patients with an ELBOW DISLOCATION which is fairly rare as most elbow fracture when subjected to this type of trauma as stated above. As opposed to shoulder dislocations, most elbow dislocations, once reduced, do not continue to dislocate. Shoulders often need surgery to avoid further dislocations whereas elbows generally remain stable. Elbows when dislocated will tear the ligaments, but when reduced, the ligaments often heal on their own. So, after the dislocation, they are treated with early splinting and rehab. Unless there is a fracture, surgery is not felt necessary, and they generally do well. If there is a fracture, since surgery is going to be performed anyways to fix the fracture, often times, the ligament is repaired during the procedure. This is a unique situation. However, as stated, in most cases the ligaments are allowed to heal naturally and only if the patient has persistent pain do we consider ligament reconstruction which occurs in less than 10% of the cases.

Ulnar Nerve Injuries

The Ulnar nerve can often become symptomatic in athletes. This is different than classic cubital tunnel syndrome where the nerve gets trapped in its tunnel and starts leading to weakness in the hand as well as numbness in the small and ring fingers.This leads to constant compression, and therefore, often requires surgery to open the tunnel and free the nerve. In athletes, they often do not have a tunnel that is entrapping the nerve but rather have nerve irritation from either an overdeveloped triceps muscle or over activity during throwing. As the triceps overdevelops, this can cause the nerve to start subluxing or sliding over the medial epicondyle which will irritate leading to numbness and tingling in the small and ring finger. This leads to similar symptoms as cubital tunnel syndrome, but because this is muscular in nature, these do respond better to conservative measures than classic cubital tunnel syndrome. However, if patients fail conservative treatment and surgery is felt necessary, this often requires moving the nerve away from the triceps muscle (transposition) and even sometimes removing a small amount of muscle. Whereas in cubital tunnel syndrome, the tunnel can just be opened in some patients. Certainly, if the nerve if subluxing, surgery is generally required. This nerve can also become symptomatic when the ulnar collateral ligament is damaged as the constant strain of the valgus instability while throwing can irritate the nerve and lead to ulnar nerve symptoms. So, it is important to evaluate for UCL injury especially in throwers prior to any consideration of nerve surgery only, as the surgery will fail if the UCL is damaged. This is best accomplished with an MRI.