UCL Repair Revolution: Advancing Care for Throwing Athletes

Introduction

Ulnar collateral ligament (UCL) injuries are becoming increasingly prevalent among young athletes, particularly in throwing sports such as baseball. These injuries can severely impact a player’s ability to throw with velocity and precision. High school, collegiate and professional pitchers are commonly undergoing surgery to reconstruct their damaged ligaments. UCL reconstruction is known colloquially as “Tommy John” surgery, named after the first professional pitcher to undergo the procedure in 1974. Since its inception, many advances have been made in the way this surgery is performed. One such technique that has been recently popularized is the concept of UCL repair. This technique offers a new hope for expedited recovery and a swift return to play, making it an attractive choice in the appropriate circumstances.

Understanding UCL Injuries

The medial ulnar collateral ligament, or UCL, is a crucial stabilizer to the medial, or inside, aspect of the elbow joint. It is the primary restraint to valgus stress of the elbow, the type of stress that is placed on the elbow during a throwing motion. Injury may occur acutely due to a sudden trauma but more commonly develops over time in athletes such as javelin throwers and baseball players. Baseball pitchers, in particular, place tremendous amounts of stress on this ligament during the motion of throwing a baseball. Over time, continued stress on the ligament leads to weakening and eventually ligament tearing. Symptoms of a UCL injury include:

• Persistent pain on the inside of the elbow
• Feeling of instability
• Decreased velocity and decreased control with throwing

In more severe cases the ulnar nerve (the “funny bone”) may also be affected due to its proximity to the ligament on the inside of the elbow. This can lead to pain, numbness or tingling radiating down the inside of the forearm or hand from the elbow. While the diagnosis of UCL injury relies heavily on history and physical exam, a physician will usually order additional tests such as an MRI or an ultrasound to further assess the ligament.

Treatment Methods

Once a diagnosis of UCL injury is made, there are several different ways it can be treated. In most cases, conservative management is attempted first. This includes:

• Rest from throwing
• A short course of an anti-inflammatory medication such as ibuprofen or naproxen
• Physical therapy, focused on strengthening the entire “kinetic chain” (which includes legs, core, and shoulder in addition to the elbow)

If these treatments fail to improve symptoms, another non-invasive measure that has shown promise is a platelet rich plasma (PRP) injection, especially in partial or low-grade tears. In more severe tears and injuries that fail to respond to conservative management, surgery is the next step in treatment.

UCL Reconstruction

The traditional surgery performed for UCL injuries is an ulnar collateral ligament reconstruction, or Tommy John surgery. This procedure is when a patient’s own tissue (most commonly a tendon in the forearm or a hamstring tendon from the leg) is harvested and placed in the elbow to function as a new UCL. This surgery is considered the gold standard in treatment of these injuries, with around 90% of players returning to their pre-injury level of function.

As with any surgery, there are risks to undergoing the procedure. While the incidence is relatively low, these risks include infection, bleeding, damage to surrounding structures in the elbow, persistent pain, failure of reconstruction, and morbidity to the site of the graft harvest. An athlete should be counseled that recovery from this procedure and return to full pitching usually takes approximately one year or more and results in missing at least one entire season of play.

UCL Repair

Due to the prolonged recovery involved in UCL reconstruction, another surgery was developed known as a UCL repair. As the name suggests, this minimally invasive procedure involves suturing the torn ligament to primarily repair the injured area rather than completely reconstructing it, eliminating the need for a graft to be harvested and placed in the elbow. This is an attractive option due to preservation of a patient’s native anatomy, smaller incisions, reduced scarring, and usually quicker surgery times. Historically, this procedure had a high rate of failure and was largely abandoned until recently.

Internal Brace Augmentation

A new advancement known as an internal brace has sparked renewed interest in this technique. This still involves repairing the damaged portion of the ligament but also adds a strong, collagen coated suture tape anchored to either side of the elbow joint to help augment the repair and provide increased strength and stability. The internal brace acts to protect the repaired ligament while it heals and has shown very promising results in recent years. While many of the risks are similar to UCL reconstruction, this technique eliminates any graft harvest and has been shown to result in a quicker recovery and return to play. Patients have been shown to return to play as early as 6 to 7 months after surgery.

While UCL repair and internal brace augmentation offer exciting possibilities, not all UCL tears will be amenable to primary repair and this technique may not be suitable for all patients. This procedure requires the native ligament to be of good quality to allow it to heal. The optimal treatment for a UCL injury depends on various factors, including:

• The severity and location of the tear
• The athlete's age and activity level
• The quality of the remaining ligament tissue

If a surgeon determines that a ligament is of poor quality and not likely to heal from a repair, a reconstruction is the next best option.

Recovery and Rehabilitation

Regardless of the chosen surgical technique, post-operative rehabilitation is crucial for a successful recovery. It is important that patients adhere to this regimen and follow up with their surgeon as scheduled to assess their progress. This process typically includes:

• An initial period of rest and protection of the repair
• Gradual range of motion exercises
• Progressive strengthening of the entire kinetic chain
• Sport-specific training and return to throwing program
• Full return to play

The timeline for return to play depends on a multitude of patient specific factors. As discussed previously, on average UCL repair with internal brace augmentation results in a faster return to play than traditional reconstruction. In general, these timelines are estimates and individual recovery times may vary.

Final Thoughts

The treatment of UCL injuries is continuously evolving, offering new hope for athletes faced with this challenging injury. UCL repair with internal brace augmentation is an exciting option for the right patient. However, it's crucial to consult with an experienced orthopedic specialist to determine the most appropriate treatment plan for your specific situation. If you are experiencing elbow pain or suspect a UCL injury, schedule a consultation with a sports medicine specialist to discuss your options and start your journey back to peak performance.

This blog was co-written by Dr. Steven B. Cohen and Dr. Frank Cautela