Ulnar collateral ligament or medial collateral ligament injuries are most common in players: baseball pitchers, gymnasts, javelin throwers etc. It mainly occurs with repetitive throwing motion which causes strain on medial collateral ligament and is known as Thrower's elbow. Injury can be of two types: overuse & traumatic injury in which overuse ligament injuries are the commonest of all. Due to muscular imbalance & faulty technique injury occurs. Common complains are pain, bruising, tenderness over the medial side of elbow and felt during movement.

1. ULNAR COLLATERAL LIGAMENT
INJURY IN ATHLETES
PRESENTED BY: DIKSHA
MPT-2ND SEM(SPORTS INJURY)
MMIPR MM(DU)
MULLANA-AMBALA,
HARYANA
MODERATED BY: DR. VANDANA ESHT
ASSOCIATE PROFESSOR
MMIPR MM(DU)
MULLANA-AMBALA, HARYANA

2. ANATOMY
• Ulnar Collateral Ligament or Medial Collateral Ligament provides stability in
the medial side of the elbow by restraining valgus forces
• It consists of three bands-Anterior bundle, Transverse bundle, Posterior
bundle
Jose Acosta Batlle, Luis Cerezal, Maria Dolores Lopez Parra, Beatriz Alba, Santiago Resano and Javier Blazquez Sanchez, The elbow: review of anatomy
and common collateral ligament complex pathology using MRI Radiology department 2019

3. INTRODUCTION
• Medial Ulnar Collateral Ligament injuries also known as
Thrower’s elbow
• Medial elbow pain is very common among baseball
pitchers as well as gymnasts, javelin thrower’s, wrestlers
• 97% of elbow pain in pitchers is located medially
• Main cause of pain is injury to Ulnar Collateral Ligament
over the medial border
• Patient may complain of pain, swelling, bruising over the
medial side of the elbow and numbness over the
fingers(4th and 5th), poorer performance
Suk-Hwan Jang, Management of Ulnar Collateral Ligament Injuries in Overhead Athletes Clinics in Shoulder and Elbow Vol. 22, No. 4,
December, 2019

4. PHASES IN THROWING MOTION
Rafael F.Escamilla, James R.Andrews. Shoulder muscle recruitment patterns and related biomechanics during Upper extremity sports,
Sports Med 2009, 39(7):569-590

5. MECHANISM OF INJURY
• In throwing motion like in pitchers, at late cocking
phase there will be an abduction and external
rotation of shoulder and flexion at the elbow(90°-
120°) this causes valgus load or force on medial
collateral ligament and can cause injury to the
ligament
• While playing if there is any fault in technique, poor
technique or weakness in the muscles it will
eventually leads to ligament injury
Brandon J. Erickson, Joshua D. Harris, Peter N. Chalmers, Bernard R. Bach, Nikhil N. Verma, Charles A. Bush-Joseph, Anthony A. Romeo. Ulnar
Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes. Orthopaedic Surgery, Erickson et al Sports Health research-
article 2015

6. MECHANISM
Jose Acosta Batlle, Luis Cerezal, Maria Dolores Lopez Parra, Beatriz Alba, Santiago Resano and Javier Blazquez Sanchez, The
elbow: review of anatomy and common collateral ligament complex pathology using MRI Radiology department 2019

7. DIFFERENTIAL DIAGNOSIS
• Tendon pathology
• Nerve impingement
• Neuritis
• Little league elbow
• Medial Epicondylitis/Golfer’s elbow
• Cubital tunnel syndrome
Heidi Edwards, Danny Smith. Sideline assessment and return to play decision making for an acute elbow ulnar collateral ligament sprain, The
International Journal of Sports Physical Therapy | Volume 8, Number 2 | April 2013 | Page 212

8. EXAMINATION
Ligament injury are categorized as:
• Grade 1: Mild (stretched but no tear)
• Grade 2: Moderate/Partial tear(25-50%)
• Grade 3: Complete tear(more than 75%)
Physical examination of elbow
• Observation-Skin color(bruising), swelling etc
• Palpation-Temperature over the joint, tenderness
over the olecranon process, medial tubercle, sublime
tubercle
Sports Rehabilitation and Injury Prevention Edited by Paul Comfort and Earle Abrahamson C 2010 John Wiley & Sons, Ltd

9. • Active range of motion- Because of the pain we get
the empty end feel
• Passive ROM
• MMT of Brachioradialis, Biceps brachi, Brachialis,
Pronators, Supinators
Special test for UCL Injuries are:
1. Milking maneuver
2. Valgus stress test
3. Moving valgus stress test
Imaging- 1. X-ray
2. Magnetic resonance imaging
3. Magnetic resonance arthrography

10. MILKING MANEUVER TEST
• Purpose: To evaluate the posterior band of
anterior bundle
• Patient Position: Sitting comfortably on the chair
• Therapist position: Stand on testing side of the
patient
• Procedure: Therapist supinate the forearm and
than extend and laterally rotate the shoulder
elbow is flexed to 90°after that examiner pulls
the patients elbow and generate the valgus force
• Sign: If patient complains of any pain than test is
positive

11. MOVING VALGUS TEST
• Purpose: To evaluate the transverse bundle
• Patient Position: Sitting comfortably on chair
• Therapist Position: Stand on testing side of patient
• Procedure: Therapist passively abduct shoulder
75° and rotate shoulder externally then flexes
elbow maximally after that rotate shoulder
externally & apply continuous valgus load to
elbow while quickly extending elbow to 30°
• Sign: When patient complains of pain from range
120°-70° while extending the elbow

12. VALGUS STRESS TEST
• Purpose: To evaluate anterior bundle of the ulnar
collateral ligament
• Patient Position: Sitting comfortably on chair
• Therapist Position: Stand on testing side of patient
• Procedure: Therapist hold the forearm of patient
between his/her trunk or forearm then flex elbow
to 20°-30° & apply valgus stress
• Sign: Along the course of UCL therapist palpate and
check for tenderness and laxity if present it
indicates UCL injury

13. X-RAY IMAGING
Image showing the avulsed and displaced medial epicondyle (M) of elbow.

14. MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging of the elbow. Alecio Lombardi, Aria Ashir, Tetyana Gorbachova, Mihra S. Taljanovic, Eric Y. Chang,
Published: 21.08.2020 Polish Journal of Radiology

15. CONSERVATIVE MANAGEMENT
STAGE 1
GOAL: Reduce pain
Reduce inflammation
Restore normal range of motion
MANAGEMENT:
• Ultrasound therapy: 0.8W/cm², for 6 minutes
• Daily icing- 10 minutes (3-4 times a day)
• Rest from pitching
• Hinged elbow brace to protect valgus stresses
• Anti-inflammatory medication
• Taping- to limit the degree of extension
• Progressive range of motion exercises of pronators and flexors

16. STAGE 2
GOAL: Strengthening of muscles
Make athlete able to return to sport
MANAGEMENT:
• Strengthening of upper limb musculature
• Strengthening protocol like throwers ten
• Close kinematic chain exercises
• Interval throwing program
Elizabeth Ehibberd, J Rodney Brown, Joseph T Hoffer. Optimal management of ulnar collateral ligament injury in baseball pitchers.
Journal of Sports Medicine 11 Nov 2015

17. SURGICAL MANAGEMENT
Jobe technique and Modified Jobe technique is most
commonly used for reconstruction surgery it also
known as Tommy John technique
INDICATION FOR SURGERY
• Failure of non-operative/conservative treatment
• Inability to return to play due to elbow dysfunction
• Desire to return to play
CONTRAINDICATION
• No desire to return to play
• Concurrent infection
• Patient noncompliance
James A. Hurt, Felix H. Savoie and Michael J. O’Brien Surgical Technique: Medial Ulnar Collateral Ligament reconstruction using hamstring allograft
.based on an original article: J Bone Joint Surg. Am. 2013 Jun 19;95(12):1062-6.

18. GRAFT CHOICE
• Palmaris longus autograft most commonly used (50-
74%)
• Others- Gracilis autograft, Hamstring allograft,
Semitendinosis autograft, Toe extensor autograft ,
Planatris autograft, Patellar tendon autograft, Achilles
autograft

19. POSTOPERATIVE PHYSIOTHERAPY TREATMENT
TIME
PERIOD
GOAL TREATMENT STRATEGIES
Day 0-10 Promote graft healing, reduce
pain, and swelling
Posterior splinted or hinged elbow with elbow immobilized at
90 degrees of flexion
Hinged elbow brace at 60 degree flexion
Week 1-4 Restore ROM 30-90 degree
Promote graft healing
Independent home exercise
program
Hinged elbow ROM brace at all times
No Passive Range of Motion
Elbow Range of Motion in brace
Week 4-6 Restore ROM 15-115 degree
Minimal pain and swelling
Continue brace wear at all times
Avoid PROM
Avoid valgus stress
Continue AROM in brace
Isometric exercises of deltoid, wrist, elbow
Week 6-12 Restore full ROM
All upper extremity strength
5/5
Begin to restore muscular
endurance
Minimal valgus stress
Avoid PROM
Avoid pain with exercises
Continue AROM
Low intensity, long duration stretch for extension
Isotonic exercises of scapula , shoulder, elbow, forearm and
wrist

20. Week 12-16 Restore full strength and flexibility
Prepare for return to activity
Pain free plyometric exercises
Advanced internal/external
rotation 90/90 position
Endurance training
Week 16 Begin interval throwing
program
Week 16-36 Return to activity
Prevent injury
Avoid pain with throwing and
hitting
Avoid loss of strength or
flexibility
Continue flexibility training
Continue strengthening
program
Week 20 Return to sport Begin hitting program

21. REFERENCES
• Jose Acosta Batlle, Luis Cerezal, Maria Dolores Lopez Parra, Beatriz Alba, Santiago Resano and Javier
Blazquez Sanchez. The elbow: review of anatomy and common collateral ligament complex pathology
using MRI Radiology department 2019
• Suk-Hwan Jang. Management of Ulnar Collateral Ligament Injuries in Overhead Athletes. Clinics in
Shoulder and Elbow Vol. 22, No. 4, December, 2019
• Brandon J. Erickson, Joshua D. Harris, Peter N. Chalmers, Bernard R. Bach, Nikhil N. Verma, Charles A.
Bush-Joseph, Anthony A. Romeo. Ulnar Collateral Ligament Reconstruction: Anatomy, Indications,
Techniques, and Outcomes. Orthopaedic Surgery, Erickson et al Sports Health research-article 2015
• Heidi Edwards, Danny Smith. Sideline assessment and return to play decision making for an acute elbow
ulnar collateral ligament sprain, The International Journal of Sports Physical Therapy | Volume 8, Number
2 | April 2013 | Page 212
• Edited by Paul Comfort and Earle Abrahamson C, Sports Rehabilitation and Injury Prevention 2010 John
Wiley & Sons, Ltd
• Alecio Lombardi, Aria Ashir, Tetyana Gorbachova, Mihra S. Taljanovic, Eric Y. Chang. Magnetic resonance
imaging of the elbow , Published: 21.08.2020 Polish Journal of Radiology
• Elizabeth E Hibberd, J Rodney Brown, Joseph T Hoffer. Optimal management of ulnar collateral ligament
injury in baseball pitchers. Journal of Sports Medicine 11 Nov 2015
• Lauren H Redler, Ryan M Degen, Lucas S McDonald, David W Altchek, Joshua S Dines. Elbow ulnar
collateral ligament injuries in athletes: Can we improve our outcomes? World J Orthopedics 2016 April18
• James A. Hurt, Felix H. Savoie, Michael J. O’Brien, Surgical Technique: Medial Ulnar Collateral Ligament
Reconstruction Using Hamstring Allograft Based on an original article: J Bone Joint Surg. Am. 2013 Jun
19;95(12):1062-6
• Rafael F.Escamilla, James R.Andrews. Shoulder muscle recruitment patterns and related biomechanics
during Upper extremity sports, Sports Med 2009, 39(7):569-590

22. TAKE HOME MESSAGE
WE SHOULD KEEP THIS CONDITION IN MIND
WHILE TREATING THE ATHLETE SO WE
DIAGNOSE THEM MORE ACCURATELY AND
TREAT THEM ACCORDING TO IT FOR EARLY
RETURN TO SPORTS
THANK YOU