Elbow Ulnar Collateral Ligament Injuries in Throwing Athletes: Diagnosis and Management

      Ulnar collateral ligament (UCL) injuries of the elbow are common in overhead throwing athletes. With throwing, the elbow experiences substantial valgus stress and repetitive microtrauma can lead to injury. Increasing rates of injury among both youth and professional throwers has resulted in a “UCL epidemic.” Ulnar collateral ligament reconstruction (“Tommy John Surgery”) became a part of the public consciousness after Tommy John returned to professional baseball after a UCL reconstruction with Dr Frank Jobe for what was once considered a career-ending injury. Partial tears and some athletes with complete UCL injuries can be managed without surgery. Since the introduction of UCL reconstruction, technical modifications have aimed to decrease complications and increase return-to-play rates. Ulnar collateral ligament repair has reemerged as a potential surgical option for some throwers. Future prospective and comparative studies are necessary to better define the optimal operative treatment for these injuries.

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        • Waris W.
        Elbow injuries of javelin-throwers.
        Acta Chir Scand. 1946; 93: 563-575
        • Bruce J.R.
        • Andrews J.R.
        Ulnar collateral ligament injuries in the throwing athlete.
        J Am Acad Orthop Surg. 2014; 22: 315-325
        • American Sports Medicine Institute
        Position Statement for Tommy John Injuries in Baseball Pitchers.
        • Cinque M.E.
        • Schickendantz M.
        • Frangiamore S.
        Review of anatomy of the medial ulnar collateral ligament complex of the elbow.
        Curr Rev Musculoskelet Med. 2020; 13: 96-102
        • Farrow L.D.
        • Mahoney A.J.
        • Stefancin J.J.
        • Taljanovic M.S.
        • Sheppard J.E.
        • Schickendantz M.S.
        Quantitative analysis of the medial ulnar collateral ligament ulnar footprint and its relationship to the ulnar sublime tubercle.
        Am J Sports Med. 2011; 39: 1936-1941
        • Buckley P.S.
        • Morris E.R.
        • Robbins C.M.
        • et al.
        Variations in blood supply from proximal to distal in the ulnar collateral ligament of the elbow: a qualitative descriptive cadaveric study.
        Am J Sports Med. 2019; 47: 1117-1123
        • Patel R.M.
        • Lynch T.S.
        • Amin N.H.
        • Calabrese G.
        • Gryzlo S.M.
        • Schickendantz M.S.
        The thrower’s elbow.
        Orthop Clin North Am. 2014; 45: 355-376
        • Torres S.J.
        • Limpisvasti O.
        Ulnar collateral ligament repair of the elbow—biomechanics, indications, and outcomes.
        Curr Rev Musculoskelet Med. 2021; 14: 168-173
        • Fleisig G.S.
        • Andrews J.R.
        • Cutter G.R.
        • et al.
        Risk of serious injury for young baseball pitchers: a 10-year prospective study.
        Am J Sports Med. 2011; 39: 253-257
        • Ahmad C.S.
        • Grantham W.J.
        • Greiwe R.M.
        Public perceptions of Tommy John surgery.
        Phys Sportsmed. 2012; 40: 64-72
        • Keller R.A.
        • Marshall N.E.
        • Guest J.M.
        • Okoroha K.R.
        • Jung E.K.
        • Moutzouros V.
        Major League Baseball pitch velocity and pitch type associated with risk of ulnar collateral ligament injury.
        J Shoulder Elbow Surg. 2016; 25: 671-675
        • Pytiak A.V.
        • Stearns P.
        • Bastrom T.P.
        • et al.
        Are the current little league pitching guidelines adequate? A single-season prospective MRI study.
        Orthop J Sports Med. 2017; 52325967117704851
        • Khalil L.S.
        • Jildeh T.R.
        • Taylor K.A.
        • et al.
        The relationship between shoulder range of motion and elbow stress in college pitchers.
        J Shoulder Elbow Surg. 2021; 30: 504-511
        • Wright R.W.
        • Steger-May K.
        • Wasserlauf B.L.
        • O'Neal M.E.
        • Weinberg B.W.
        • Paletta G.A.
        Elbow range of motion in professional baseball pitchers.
        Am J Sports Med. 2006; 34: 190-193
        • Rutter M.
        • Grandizio L.C.
        • Malone W.J.
        • Klena J.C.
        The use of preoperative dynamic ultrasound to predict ulnar nerve stability following in situ decompression for cubital tunnel syndrome.
        J Hand Surg Am. 2019; 44: 35-38
        • Chen F.S.
        • Rokito A.S.
        • Jobe F.W.
        Medial elbow problems in the overhead-throwing athlete.
        J Am Acad Orthop Surg. 2001; 9: 99-113
        • Cain E.L.
        • Andrews J.R.
        • Dugas J.R.
        • et al.
        Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: results in 743 athletes with minimum 2-year follow-up.
        Am J Sports Med. 2010; 38: 2426-2434
        • Molenaars R.J.
        • Medina G.I.S.
        • Eygendaal D.
        • Oh L.S.
        Injured vs. uninjured elbow opening on clinical stress radiographs and its relationship to ulnar collateral ligament injury severity in throwers.
        J Shoulder Elbow Surg. 2020; 29: 982-988
        • Ramkumar P.N.
        • Frangiamore S.J.
        • Navarro S.M.
        • et al.
        Interobserver and intraobserver reliability of an MRI-based classification system for injuries to the ulnar collateral ligament.
        Am J Sports Med. 2018; 46: 2755-2760
        • Frangiamore S.J.
        • Lynch T.S.
        • Vaughn M.D.
        • et al.
        Magnetic resonance imaging predictors of failure in the nonoperative management of ulnar collateral ligament injuries in professional baseball pitchers.
        Am J Sports Med. 2017; 45: 1783-1789
        • Ford G.M.
        • Genuario J.
        • Kinkartz J.
        • Githens T.
        • Noonan T.
        Return-to-play outcomes in professional baseball players after medial ulnar collateral ligament injuries: comparison of operative versus nonoperative treatment based on magnetic resonance imaging findings.
        Am J Sports Med. 2016; 44: 723-728
        • Chauhan A.
        • McQueen P.
        • Chalmers P.N.
        • et al.
        Nonoperative treatment of elbow ulnar collateral ligament injuries with and without platelet-rich plasma in professional baseball players: a comparative and matched cohort analysis.
        Am J Sports Med. 2019; 47: 3107-3119
        • Dugas J.R.
        • Looze C.A.
        • Capogna B.
        • et al.
        Ulnar collateral ligament repair with collagen-dipped FiberTape augmentation in overhead-throwing athletes.
        Am J Sports Med. 2019; 47: 1096-1102
        • Savoie III, F.H.
        • Trenhaile S.W.
        • Roberts J.
        • Field L.D.
        • Ramsey J.R.
        Primary repair of ulnar collateral ligament injuries of the elbow in young athletes: a case series of injuries to the proximal and distal ends of the ligament.
        Am J Sports Med. 2008; 36: 1066-1072
        • Jobe F.W.
        • Stark H.
        • Lombardo S.J.
        Reconstruction of the ulnar collateral ligament in athletes.
        J Bone Joint Surg Am. 1986; 68: 1158-1163
        • Thompson W.H.
        • Jobe F.W.
        • Yocum L.A.
        • Pink M.M.
        Ulnar collateral ligament reconstruction in athletes: muscle-splitting approach without transposition of the ulnar nerve.
        J Shoulder Elbow Surg. 2001; 10: 152-157
        • Rohrbough J.T.
        • Altchek D.W.
        • Hyman J.
        • Williams R.J.
        • Botts J.D.
        Medial collateral ligament reconstruction of the elbow using the docking technique.
        Am J Sports Med. 2002; 30: 541-548
        • Conway J.E.
        The DANE TJ procedure for elbow medial ulnar collateral ligament insufficiency.
        Tech Shoulder Elb Surg. 2006; 7: 36-43
        • Shah R.P.
        • Lindsey D.P.
        • Sungar G.W.
        • McAdams T.R.
        An analysis of four ulnar collateral ligament reconstruction procedures with cyclic valgus loading.
        J Shoulder Elbow Surg. 2009; 18: 58-63
        • Watson J.N.
        • McQueen P.
        • Hutchinson M.R.
        A systematic review of ulnar collateral ligament reconstruction techniques.
        Am J Sports Med. 2014; 42: 2510-2516
        • Looney A.M.
        • Wang D.X.
        • Conroy C.M.
        • et al.
        Modified Jobe versus docking technique for elbow ulnar collateral ligament reconstruction: a systematic review and meta-analysis of clinical outcomes.
        Am J Sports Med. 2021; 49: 236-248
        • Clain J.B.
        • Vitale M.A.
        • Ahmad C.S.
        • Ruchelsman D.E.
        Ulnar nerve complications after ulnar collateral ligament reconstruction of the elbow: a systematic review.
        Am J Sports Med. 2019; 47: 1263-1269
        • Leslie B.M.
        • Osterman A.L.
        • Wolfe S.W.
        Inadvertent harvest of the median nerve instead of the palmaris longus tendon.
        J Bone Joint Surg Am. 2017; 99: 1173-1182
        • Savoie III, F.H.
        • Morgan C.
        • Yaste J.
        • Hurt J.
        • Field L.
        Medial ulnar collateral ligament reconstruction using hamstring allograft in overhead throwing athletes.
        J Bone Joint Surg Am. 2013; 95: 1062-1066

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