Ulnar Collateral Ligament Rehabilitation

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Ulnar Collateral Ligament Rehabilitation

• By Michael Cox

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Bony Anatomy

• Humerous
• Medial epicondyle- trochlea which serves as the
  axis of rotation for ulna on the humeorus
• Lateral epicondyle- capitellum which serves as
  the axis of rotation for the radius
• Radial fossa- accepts radial head during flx
• Coranoid fossa- accepts coranoid process during
  flx
• Olecronon fossa- accepts olecronon during ext
• Ulna
• Olecronon process
• Coranoid process
• Radius
• Radial head
• Radial tuberosity

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Bony Anatomy

• Humeroulnar joint
• Hinge joint
• Strong and stable
• Allows for flexion and extension
• Humeroradial joint
• Modified ball and socket joint
• Proximal radioulnar joint
• Allows for pronation and supination

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Ligamentous support

• Ulnar Collateral Ligament
• Resists valgus loads
• 3 bundles
• Anterior- taut throughout full ROM,
• primary restraint against valgus stress
• Transverse- provides little medial support
• Posterior- taut in flexion beyond 60 degrees
• Lateral Collateral Ligament
• Resists varus forces
• Composed of radial collateral ligament,
• lateral ulnar collateral ligament,
• annular and accessory ligament
• Annular Ligament
• Encases radial head
• Doesnt let ulna and radius move into
• flexion and extension independently

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Musculature

• Flexors
• Biceps brachii, brachioradialis, brachialis
• Extensors
• Triceps brachii, anconeus
• Forearm Pronators
• Pronator teres, pronator quadratus
• Forearm Supinators
• Supinator, assisted by biceps and brachioradialis

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Mechanism of Injury

• Most ulnar collateral ligament injuries
• occur in overhead throwing athletes
• This due to the extreme valgus stress
• placed on the elbow throughout the throwing
  motion
• Acutely the UCL can also be injured
• with a lateral blow to the elbow

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Clinical Evaluation

• The patient will complain of pain on the medial
  aspect of the elbow that increases with motion
• Tingling or numbness may be present due to the
  tensile force placed on the ulnar nerve
• Point tender from the along the medial epicondyle
• Some swelling may be noticeable
• Positive valgus stress test

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Acute treatment

• Refer patient for a MRI
• Restrict any throwing movements
• Can sling if more comfortable
• Modalities can be used to help reduce pain and
  inflammation such as ice and electrical
  stimulation for gate theory pain control

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Surgical Patients

• If surgery Is needed- Tommy John- usually uses
  palmaris longus tendon as a graft to replace UCL
• Immobilization wit the arm at 90 degrees of
  flexion for 10-14 days
• At this time wrist and finger ROM exercises can
  be started
• Gripping exercises with puddy
• Shoulder ROM

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Beginning Rehabilitation

• Weeks 0-3
• Goals
• Decrease pain and inflammation
• Improve ROM
• Retard atrophy

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Early Rehab- Passive ROM

• Passive extension with dumbbell hanging off table
  (towel under joint)
• 2 lbs.for 5-7 minutes (long duration, low
  intensity stretch)
• Pulley flexion and extension
• 3 sets- 10 repetitions
• Clinician passive ROM

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Early Rehab- Active ROM

• Wand exercises 3 sets- 10 repetitions
• flexion
• extension
• pronation
• supination
• Wrist ROM
• Active ROM
• flexion, extension, pronation, supination

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Early Rehab- Decreasing Pain

• Joint Mobilizations- grade I and II oscillations-
  posterior glide
• Ice
• Electrical Stim
• - gate theory

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Early Rehab- Strengthening

• Isometrics
• flexion, extension, pronation, supination
• 3 sets of 10 repetitions holding contractions for
  about 5-10 seconds
• Refrain from internal and external rotation due
  to the valgus stress it places on the UCL

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Intermediate Rehabilitation

• Weeks 4-8
• Goals
• Improving strength and endurance
• Reestablishing neuromuscular control
• Maintain full ROM
• Criteria Near total ROM with minimal pain

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Intermediate Rehabilitation

• Isotonic exercises
• Flexion
• extension
• pronation
• supination
• 3 sets- 10 repetitions
• Starting at 2lb dumbbell and progressing as
  strength increases
• Wrist isotonic exercises
• Rhythmic Stabilization
• clinician assisted
• swiss ball
• 4 sets- 20s

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Intermediate Rehabilitation

• Diagonal PNF patterns
• Body Blade
• straight arm and at 90

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Moderate Rehabilitation

• Weeks 9-13
• Goals
• Advanced strengthening phase
• Increase total arm strength, power, endurance,
  and neuromuscular control
• Prepare patient for functional return to play
  activities
• Criteria
• Full non painful ROM
• Strength close to 70 of uninvolved limb

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Moderate Rehabilitation

• Eccentric training
• Theraband- biceps and triceps

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Moderate Rehabilitation

• Throwers 10- total arm strength
• Dumbbell abduction
• Prone dumbbell abduction
• Prone extension
• Internal rotation
• External rotation
• Theraband shoulder flexion and extension
• Progressive pushups
• Medicine ball punches- serratus anterior
• Diagonal D2 PNF
• Wrist flexion, extension, pronation, supination

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Moderate Rehabilitation

• Plyometrics
• Med ball throws one hand
• Soccer throw
• Chest pass
• Side to side
• Plyometric press up

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Moderate Rehabilitation

• Progressive medicine ball plyometrics
• Increased soccer throws
• 8-10 reps
• Side hits
• 2 sets- 30 seconds
• External rotation throws
• 3 sets- 10 reps

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Final Rehabilitation

• Weeks 14-26
• Goal
• Progressive functional drills
• Continue to increase strength, endurance, power
• Return to play
• Criteria
• Full ROM with no pain
• Full strength

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Final Rehabilitation

• Throwing program
• Increase in distance and amount of throws
• Enough rest time in-between session 2-3 days
• Batting practice
• Tees
• Soft toss
• Slow pitching
• Against a pitcher

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Return To Play

• Full ROM
• Full strength
• No direct pain with throwing or hitting
• Normal cardiovascular endurance
• Physiologically ready

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Article

• Emphasizes maintaining full elbow extension early
• Important to strengthen elbow and wrist flexors,
  and pronators- importance in follow through phase
• Rotator cuff strength
• Progressive and essential rehabilitation program

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Summary

• Elbow joint has strong bony support as well as
  ligamentous and capsular support
• Mechanism of injury is usually repetitive valgus
  stress
• Progressive rehab with certain criteria that must
  be met before moving on
• Avoid internal and external rotation early in
  rehab due to valgus stress it places on elbow
• Maintain cardiovascular endurance and core
  strength throughout rehab
• Flexibility
• Continue strengthening once back to full
  participation to decrease risk of re-injury

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Questions

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