How to Treat Ulnar Collateral Ligament Injuries in Athletes

Medial Elbow Injuries in Throwing Athletes

Injuries to the ulnar collateral ligament (UCL) can cause elbow pain. And prevention of a UCL tear is focused on avoiding excessive elbow movements, such as the motion you would make when pitching a baseball. The UCL is on the medial (inner) side of the elbow, and it helps to provide stability to the joint. When throwing, significant stress is placed on the UCL, and it can be injured or torn.

Injuries to the UCL can sometimes be treated with a procedure that's often called Tommy John surgery.

Baseball pitcher throwing a ball
Matt Brown / Getty Images

Symptoms of UCL Injuries

The most common symptom of a UCL injury is pain directly over the ligament on the inner side of the elbow. 

With a UCL injury, you may notice:

  • Pain, most commonly in the 'late cocking' phase of throwing (when the ball is up, and behind the head)
  • A 'popping' sensation when the pain begins
  • Numbness or tingling in your hand and fingers
  • A decrease in your pitch velocity

However, not every elbow pain in a throwing athlete is a UCL injury, and it's important that you have a physical examination to determine the cause of your elbow pain. 

Tendinitis of the muscles on the inner side of the elbow (the wrist flexor muscles) is the most common cause of symptoms that are similar to those of UCL injury symptoms. Usually, tendinitis begins more gradually than UCL injuries, but the conditions are commonly confused. Ulnar nerve problems can also cause pain and nerve-related symptoms in the same area.

Preventing UCL Injuries

One of the big fears of baseball pitchers and other athletes who throw as part of their sport is having a UCL injury. Tommy John may be better known by younger baseball fans not for his accomplishments on the pitcher's mound, but for the surgical procedure that bears his name. 

There is concern among physicians that the rate of UCL injuries is increasing, possibly as a result of baseball pitchers throwing too much, too often, and at a younger age. Furthermore, summer baseball has evolved into a year-long activity for many young athletes, further subjecting the elbow to repeated stress.

Tommy John surgery can require over a year of recovery and is not a guarantee to return to the same level of throwing, so the importance of preventing UCL injuries is paramount. The USA Baseball Medical/Safety Advisory Committee has made specific recommendations about how many pitches different age athletes should be limited to throw over the course of a game and a week, and how much rest they should have after throwing. All coaches at every age level should be familiar with these limits.

Any early signs of elbow discomfort in a young athlete should be treated with urgency. Throwers who develop elbow pain should be removed from competition immediately and assessed by a medical professional. A throwing progression should always be performed before returning to pitching, even if the cause is thought to be unrelated to an injury to the UCL.

UCL Injury Treatment

Most athletes who sustain an acute injury to the UCL will be given nonsurgical treatment first. Immediate rest of the painful elbow should be followed by a physical therapy evaluation. Physical therapy should include a careful assessment of the player's throwing mechanics to determine methods to lower the stress placed on the injured ligament.

Surgical treatment involves reconstructing a new ligament, not repairing the damaged ligament. The new UCL is made from the palmaris longus tendon, a tendon in the forearm. Most, but not all, of us have a palmaris longus tendon, but we don't need it. If you don't have a palmaris longus tendon, there are other tendons that can be used for the construction of the new ligament.

Once the graft for the new ligament has been removed from its original place in your body, your surgeon will make small drill holes above and below the elbow joint where the UCL attaches to the bone. The tendon graft will be pulled through the holes, wrapped in a figure-of-8 style, and sewn back upon itself to create the new ligament.

Rehabilitation after UCL surgery takes almost a year. Most athletes do not begin any throwing until at least four months after surgery, and the progression of recovery is slow. Some athletes return to full strength by nine months, although many take more than a year to fully recover.

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By Jonathan Cluett, MD
Jonathan Cluett, MD, is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the United States men's and women's national soccer teams.