Operative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Athletes.

Operative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Athletes Azar FM, Andrews JR, Wilk KE, Groh D (American Sports Medicine Institute, Birmingham, Ala), Am J Sports Med. 2000;28:16-23.

The authors retrospectively assessed the results of ulnar collateral ligament reconstruction and repair in athletes of all skill levels in order to recommend interventions for injuries to this ligament.

Subjects who received surgery on the ulnar collateral ligament of the elbow that was performed by one of the authors between 1988 and 1994 were selected for this study. This resulted in a total of 91 subjects with surgically treated elbows: 78 were reconstructed, 13 were repaired. The demographics of the cohort were as follows: all subjects were male; 96.7% of the injured elbows were on the dominant side; baseball players comprised 93.4% of the subjects, and the remaining subjects played football, wrestled, or played tennis; 1 subject sustained the injury during a fall. The authors focused on the 85 subjects who were baseball players, describing the level of sport participation (eg, professional [44%], collegiate [48%], high school or recreational [8%]) as well as the position played (80% were exclusively pitchers). Onset of symptoms was discussed as occurring suddenly in 68.1% of the baseball players, whereas insidious onset accounted for the remaining 31.9%. In the baseball cohort, correlation of symptoms with phases of the throwing motion was recorded. In addition to the time frame between onset of symptoms and surgical intervention, the authors also documented previous surgeries in 14 of the 91 subjects.

The preoperative evaluation included history, physical examination and review of systems, and the athlete's sport and level of play. The authors further described the activities of those involved in throwing activities versus pitching. For example, throwers were questioned about style, velocity, and accuracy, while pitchers were asked about average pitch count, number of innings pitched, and types of pitches thrown. The physical examination was operationally defined by the specific components incorporated, including the results of the findings for the cohort. Finally, the authors included a computed tomography arthrogram or saline-enhanced magnetic resonance imaging (MRI) for detection of ulnar collateral ligament tears or ruptures in these subjects as well as standard radiographs.

Surgical intervention was indicated in those subjects with a complete tear of the anterior bundle of the ulnar collateral ligament. Surgery was considered for subjects with partial-thickness tears, if 3 months of nonoperative conservative treatment failed. In the majority of subjects, the palmaris longus tendon from either the ipsilateral or contralateral limb was used as the autograft. Toe extensor or plantaris tendon autografts were employed in 11.5% and 7.7% of the surgical procedures, respectively. The authors illustrated the surgical procedure in,depth, including subcutaneous transposition of the ulnar nerve.

Postoperative rehabilitation consisted of 4 phases. Phase I began immediately after surgery and lasted 3 weeks. During this phase, the subject's arm was immobilized in a posterior splint fixed at 90 degrees of elbow flexion. Progression to a motion-limiting brace occurred after 8 days. Motion was initially limited from 30 to 100 degrees, increased to 15 to 110 degrees at week 3, and then continually increased by 5 degrees of extension and 10 degrees of flexion every week afterwards. At week 3, submaximal isometric contractions at the shoulder and arm were initiated.

Phase II occurred 4 to 8 weeks after the operation. At 8 weeks, the brace was discontinued, and full range of motion was achieved. Isotonic exercises were begun, which focused on periscapular muscle and external rotators of the rotator cuff as well as the strengthening of the elbow and wrist. The authors commented on specific weights used with their athletic population. The subjects started with 1 lb at postoperative day 12 to 14 and increased the weights by 1 lb per week through week 8.

Phases III and IV were considered the advanced strengthening phase. During phase III (weeks 9 to 14), a sport-specific rehabilitation program was incorporated, which included strengthening and flexibility exercises for the upper extremity and scapular region. Proprioceptive neuromuscular facilitation and stabilization exercises were included in the athlete's program. Plyometric activities specific to the throwing motion were initiated at week 12. The authors described phase IV specifically for the baseball player. This phase concentrated on return to activity and lasted until week 26. This phase emphasized an interval throwing program.

Of the original 91 subjects, 67 were available for follow-up (mean follow-up time=35.4 months, range=12 to 72 months). Fifty-three subjects (79%) had successful outcomes. Forty-eight (81%) of the 59 subjects who received reconstructions and 5 (63%) of the 8 subjects who received repairs returned to their previous level of competition or to higher levels. Only 10 subjects were unable to return to sports at their previous level or to return to sports at all because of the nature of their elbow injuries. Of the 10 subjects who had neurologic impairment prior to surgical procedures, 9 subjects had total resolution of this impairment. Complications due to the surgical procedure, which were primarily related to problems at the graft site, were discussed.

A comprehensive discussion section reviewed and related this study's findings to previously cited literature. The authors reported that this study supports the literature regarding use of MRI for diagnostic testing. In addition, the authors concurred with previous studies that demonstrated failure of isolated repair of a torn ulnar collateral ligament. The authors discussed changes in their rehabilitation program concerning the motion brace and implementation of the interval-throwing program. In conclusion, the authors recommended reconstruction of the ulnar collateral ligament rather than repairing the ligamentous tear, based on their good-to-excellent outcomes in this population of male athletes.

Aimee Klein, PT, OCS MGH Institute of Health Professions Boston, Mass