What is the ulnar collateral ligament?

The ulnar collateral ligament is the primary stabilizer of the elbow during throwing and overhand sports. It can be injured from major trauma such as an elbow dislocation, or repetitive micro trauma such as throwing a baseball. If the ligament is relatively health but just peeled off the humerus or ulna, a repair is possible. If it is chronically damaged and unhealthy in structure, a reconstruction of the ligament is done using a tendon from the forearm or leg. The recovery after a repair is usually approximately 6 months. A reconstruction usually requires 9 to 12 months before a patient can return to their sport.

Indications for Surgery

When the ulnar collateral ligament is injured, usually the first line of treatment is rest and physical therapy. It is common to have the patient work with a throwing specialist to evaluate the mechanics of their throwing motion to assure there is no unnecessary force being applied to the medial elbow. If these methods fail to result in a stable and pain free elbow, surgery is commonly recommended. The goal of surgery is to recreate a stable elbow for activities of daily living and returning to sports.

Surgical Procedure

UCL Repair can be done if the ligament is relatively healthy but due to the injury it is not attached on one side of the elbow. It is repaired back to the bone with an anchor and strong sutures to support the ligament while it heals. This is called an internal brace.

UCL Reconstruction is a procedure done when the tissue of the ligament is very damaged and not repairable. In this surgery a tendon from the forearm or leg is borrowed and used to rebuild the ligament. The tendon is placed in the anatomic location of the original UCL and it is anchored to the bone on both sides of the elbow. With time the body remodels the ligament and turns it into a new UCL.

The surgery is done as an outpatient procedure. Your arm will be splinted in a plaster splint for 10 to 14 days. The splint has to be kept clean and dry to prevent complications. It is also used to help control swelling and pain. At the first post-operative appointment the splint will be removed and the arm will be placed in a brace locked at 90 degrees of flexion. After that appointment, you will begin your rehabilitation.

Rehabilitation Protocol

Phase 1: Weeks 2 to 6

  • The splint is removed
  • The arm will be placed in a brace locked at 90 degrees.
  • The brace will be removed daily for PT
  • PT will focus on decreasing the swelling and passive and active range of motion will be advanced gradually
  • The brace can slowly be opened up to flexion and extension over the 6 weeks based on the patients comfort and PT progress
  • Light contraction of the muscles that function in the plane of elbow, i.e. flexion and extension will begin
  • Ice will be used to control swelling and inflammation
  • Goal is to attain nearly 0 to 140 degrees of ROM by week 6

Phase 2: Weeks 6 to 12

  • Continue Active and Passive range of motion exercises
  • Begin to progress strengthening
  • Initiate light resistance exercises and isometrics including flexion, extension, pronation, supination, and wrist flexion and extension
  • Incorporate shoulder exercises and RTC program and scapular stabilization
  • Avoid valgus stress of the elbow in PT and home activities of daily living, i.e. be careful picking up a heavy bag or closing a heavy door etc.
  • Begin scar massage and scar cream if necessary
  • The brace may be discontinued per PT when they feel the patient has the strength, stability and range of motion. Usually by 8 weeks.

Phase 3: Weeks 12 to 16

  • Progress strength and endurance of the elbow, shoulder and core as tolerated
  • Begin light throwing activities, i.e. throwing a ball against a wall or to a therapist from short distances

Phase 4: Weeks 16 to 24

  • May begin a 10 point return to throwing program

Phase 5: Return to Sport

  • UCL Repair with internal brace should be able to return to sport at 6 months post operatively

UCL reconstruction goal is to return to sport at 9 to 12 months post operatively. The step wise return to throwing program is advanced more slowly when there is a reconstruction since it takes longer for the ligament graft to become strong enough to handle the forces of the throwing motion.