Ulnar Collateral Ligament (UCL) Injuries – Causes, Symptoms, Treatment and Prevention
What is the ulnar collateral ligament?
The elbow joint is formed by three bones: the humerus (the upper arm bone), the ulna (the larger bone of the forearm, on the opposite side of the thumb), and the radius (the smaller bone of the forearm on the same side as the thumb).
The elbow itself is a hinge joint, meaning it bends and straightens like a hinge. But there is a second joint where the end of the radius meets the humerus that allows the radius to rotate so that the hand can turn.
There are approximately 900 ligaments in the human body. A ligaments role is to connect bones together at a joint. They act to stabilise joints, support the bones and prevent the bones from grinding into each other. Ligaments have a limited amount of stretching ability, which protects joints from injury. The ulnar collateral ligament (UCL) connects the inside of your upper arm bone (humerus) to the inside of one of your forearm bones (the ulna). The UCL also known as the medial collateral ligament of the elbow, provides support to the elbow joint when performing certain motions, such as throwing a ball. When this ligament is torn or damaged, it can lead to pain, elbow instability and loss of function. An ulnar collateral ligament injury may at first cause pain and tightness in the area, however over time and with repetitive stress or trauma, the UCL can become stretched and tear.
The ulnar collateral ligament can be divided up into three portions:
- Anterior (front) bundle
- Intermediate/transverse (across) bundle
- Posterior (back) bundle
Together, these three bundles form the collateral ligament complex.
How do UCL injuries happen?
The ulnar collateral ligament of the elbow is most often injured by repeated stress from overhead movements. This motion is common in sports that involve throwing, such as baseball and javelin. More commonly, a ulnar collateral ligament injury occurs gradually over time and with repeated stress but it can also be injured due to a single traumatic event. Ulnar collateral ligament injuries can range from complete tears to less severe damage such as inflammation.
UCL Tears From Overuse
A ulnar collateral ligament tear occurs with overuse and wear and tear on the ligaments in the elbow and is most commonly associated with baseball pitchers and other athletes who perform frequent overarm movements. The UCL can become stretched, frayed or torn through the stress of repetitive throwing motions. If the force on the ligament is greater than the tensile strength of the structure, then tiny tears of the ligament can develop. Months to years of throwing fast can cause micro-tears, degeneration, and finally, rupture of the ulnar collateral ligament. Eventually the weakened tendon may rupture completely causing a pop and immediate pain. The athlete may report the injury occurred during a single throw, but in reality, it is more likely that the ligament simply became weakened to the point that it finally ruptured.
UCL Injuries in Children
As youth sports participation increases, so too does the incidence of paediatric elbow injuries. Longer sport seasons with extended practice time and more tournaments increase the risk of ulnar collateral ligament injury in children and adolescents.
Pain when throwing is not normal for young children. If reported, it should be addressed immediately to prevent further injury. Some common causes of ulnar collateral ligament injuries in children include:
- Forced twisting motion of the arm
- Falling on an outstretched arm or hand
- Repeated overhead movement (such as in pitching, volleyball, or tennis)
Traumatic UCL Injuries
Although less common, traumatic injuries of the ulnar collateral ligament do occur. These are often abrupt injuries and can result in a complete UCL tear or rupture of the ligament. Most often a traumatic UCL injury is caused from a fall on an outstretched hand or from landing in a compromising position during sport participation such as gymnastics or wrestling.
What are the symptoms of a UCL injury?
With a UCL injury, you may experience symptoms such as:
- Soreness or tightness along the inside of your elbow.
- A sudden “pop” or pain along the inside of the elbow, leading to the inability to continue throwing.
- Elbow pain
- Pain on the inside of the elbow after a period of heavy throwing or other overhead activity.
- Pain when accelerating the arm forward, just prior to releasing a ball.
- Minor swelling and possible bruising along the inside of your arm.
- Possible numbness and tingling in your arm.
- Instability at your elbow joint (a feeling like your elbow might “give way” when you move it through certain motions).
- Pain when using your arm in an overhead position (eg, throwing/pitching a ball, swinging a racquet).
- Poorer performance (eg, a decrease in pitching speed).
How are UCL injuries diagnosed?
A Physiotherapist will conduct a thorough evaluation and a diagnosis will be made based on the history and symptoms of the client. Common questions that are asked when querying an UCL injury include:
- When and how did this injury occur? (Sudden or gradual?)
- How long have you had pain?
- Have you had any numbness and tingling in your arm?
- Did you feel a “pop” near your elbow when throwing or performing an overhead activity?
- Have you experienced any instability (eg, a feeling of your arm “giving out”) when performing an overhead activity?
- Have you experienced a decrease in job or sport performance?
- What other sports or activities do you participate in?
- Have you had to stop playing your sport, or performing your job, because of the injury to your elbow?
An examination of the shoulder and elbow will be performed and the Physiotherapist will perform specific tests to look for areas of laxity (looseness). Most clients will report tenderness along the inside of the elbow when the UCL is palpated. To provide a definitive diagnosis, your Physiotherapist may order further tests, such as magnetic resonance imaging (MRI) to assess for UCL tears and confirm the diagnosis.
How are UCL injuries treated?
The treatment of UCL injuries ranges from rest and Physiotherapy to the need for surgical intervention, depending on the severity of the injury and the health goals of the client. Most UCL injuries can be managed successfully without the need for invasive procedures.
Nonsurgical UCL Treatment
The aim of nonsurgical UCL treatment is to stabilise the elbow joint, improve strength and range of motion and help restore confidence in the injured area. When managing a UCL conservatively a Physiotherapist will:
- Decrease the stress across the injured area to promote healing of the UCL injury. Your Physiotherapist will likely encourage you to take some time off from your sport or other activity and encourage the use of ice and compression.
- Strengthen your muscles. After an UCL injury, it is likely that your arm will feel weaker. Strengthening the muscles of your shoulder, upper back, and shoulder blades in addition to those of the forearm will help decrease the stress at the elbow joint.
- Improve your range of motion. Your Physiotherapist will work with you to improve your arm’s range of motion, including stretching your shoulder to help decrease stress on your elbow when performing overhead movements.
- Correct your movements. While every sport requires different arm positions, certain positions may put an athlete at greater risk for injury to the elbow. Examining and modifying the movements you perform may help you safely return to your sport. Your Physiotherapist will help design a specific program to allow a gradual full return to activity.
- Prepare to return to sport.
Surgical repair of the UCL (Tommy John Surgery) remains the gold standard for complete UCL tears, which occur most commonly in professional athletes.
UCL reconstruction or ‘Tommy John Surgery’ uses a tendon graft taken from somewhere else in the body, or from a donor, to serve as a new UCL. Tunnels are drilled in the bones (ulna and humerus) to secure the new ligament. Remnants of the original ligament may be attached to the new tendon to strengthen it.
How long does recovery after a UCL injury take?
If UCL reconstruction is performed, the rehabilitation will likely take nine months to a year, and sometimes longer if the goal is to return to sport that requires throwing.
The phases of a guided Physiotherapy rehab for UCL reconstruction will include:
Phase 1: Immediate Postoperative Phase (weeks 0-3)
- The elbow is placed in a hinged brace to immobilise the joint and protect healing tissue.
- Decrease pain/inflammation
- The hinged brace is adjusted until the elbow can be fully extended.
- Gentle exercise for the wrist, hand, arm and shoulder.
- Cryotherapy (ice)
- Total body conditioning exercise.
Phase 2: Intermediate Phase (weeks 4-8)
- Functional brace set (10° to 120°). Discontinue brace at 6 weeks to 8 weeks postoperatively.
- Begin specific elbow strengthening exercises
- Avoiding exercises that may place too much stress on the graft before it has healed to decrease the risk of failure.
Phase 3: Advanced Strengthening Phase (weeks 9-13)
- Increase strength, power, and endurance
- Maintain full elbow range of motion
- Gradually initiate sporting activities
- Facilitate long term plan
Phase 4: Return-to-activity phase (weeks 14-26)
- Continue to increase strength, power, and endurance of upper extremity musculature
- Gradual return-to-sport activities
- Gradual return to competitive throwing
Make an appointment
If you have elbow pain or instability or if you are having difficulty performing throwing motions in your chosen sport, speak to one of our Physiotherapist’s at Pillar Health about how they can help. Call 03 8899 6277 or book online to speak with one of our Physiotherapist’s today.