Nonoperative Management of Ulnar Collateral Ligament Injuries in the Throwing Athlete: A Framework for Return to Throwing

Abstract

Background:

Ulnar collateral ligament (UCL) injuries in throwing athletes result from repetitive valgus stress to the elbow in a flexed position. Muscular dysfunction of the forearm and shoulder musculature is commonly associated with UCL injuries. Nonoperative rehabilitation should generally start with a rest period, followed by progressive strengthening of the upper extremity, and eventually, a systematic throwing program.

Indications:

Nonoperative management is first line for UCL injuries. Trained rehabilitation professionals, including physical therapists or athletic trainers, should be involved early and guide the progression of exercise throughout the recovery process.

Technique Description:

In the first 1 to 2 weeks, the goals include strengthening rotator cuff, scapulothoracic, and forearm musculature while protecting the damaged UCL by avoiding valgus stress. Weeks 3 to 4 progress strengthening to more demanding movements, utilizing larger muscle groups while introducing shoulder internal rotation strengthening. The goals of weeks 5 to 6 are to increase the speed of movement as the athlete prepares to return to more throwing-like activity. The athlete can begin a progressive, monitored throwing program as early as 7 weeks.

Results:

The purpose of this video is to provide a suggested framework for the progression of rehabilitative exercises in athletes with UCL injuries.

Discussion/Conclusion:

A well-designed return to throwing program respects tissue load tolerance. It is important that the athlete remain pain-free throughout the rehabilitation process. This highlights the need for well-trained professionals to guide the return to throwing process, so that modifications can be made when needed.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This presentation on nonoperative management of ulnar collateral ligament (UCL) injuries and the throwing athlete was created by both Virginia Commonwealth University Department of Orthopaedic Surgery in Richmond, Virginia, and Redemption Physical Therapy and Performance in Midlothian, Virginia.

We have no disclosures.

Background

The objectives of this video are listed here.

There are 3 portions of the UCL. The anterior bundle is the primary stabilizer of the medial elbow. The posterior bundle provides supplemental resistance to valgus instability at 90° to 120° of elbow flexion. The oblique bundle originates and attaches on the ulna and, therefore, does not provide any stability to the humeroulnar joint. The mechanism of UCL injury is repetitive valgus stress.

In addition to the passive ligamentous stability provided by the UCL, the flexor-pronator muscle group provides dynamic stability to the medial humeroulnar joint. Dysfunction to this muscle group is associated with UCL injury.^5,6 Similarly, rotator cuff weakness is also associated with UCL injury in throwers. ⁴ Full assessment of the kinetic chain should be performed to detect any dysfunction in the core and lower extremities as well.

These images are adapted from Kibler and Sciascia’s ⁸ article on the evaluation of scapular dyskinesis. They demonstrate 2 methods of testing scapular motor control and strength: the scapular assistance test and manual muscle testing of the shoulder girdle in a position of scapular retraction versus protraction.

Although evaluation of the core can be a complex process, here we provide an example of a quick test to check abdominal control in the overhead position. This is the supine shoulder flexion with dowel test. If athletes have trouble keeping their low back flat on the floor as they flex the shoulder into maximal flexion, they likely have either an abdominal motor control issue or lack sufficient latissimus dorsi flexibility.

On initial evaluation, a patient with a UCL injury will likely present with complaints of medial elbow pain. Throwers will often report decreased throwing velocity, control, and accuracy.

On exam, the patient will likely have tenderness to palpation along the medial elbow. Several special tests can be used to assess UCL integrity. The milking maneuver is pictured to the right. The valgus stress test is commonly used, but the more sensitive test is the moving valgus stress test, which tests the UCL in varying degrees of elbow flexion.^3,7,10 These physical exam maneuvers are demonstrated later in this video, around the 8:30 mark. Magnetic resonance imaging is the gold standard for diagnosis of UCL tears. When combined with arthrography, the sensitivity is found to be 86° for partial tears and 95° for complete tears.^1,9,11

Indications

Most UCL tears in the throwing athlete are partial tears of various grades. For some low-grade partial tears, there are certainly considerations for nonoperative management. In a systematic review by Cascia et al, mean return-to-play rate was found to be 78% across 7 studies of partial UCL tears managed nonoperatively.^2,3 Nonoperative management offers the athlete both a chance to return to sport at an earlier time point and the potential to avoid the risks associated with surgical intervention. Nonoperative management typically involves a 1- to 2-week rest stage with nonsteroidal anti-inflammatory drugs, followed by a gradual strength and rehabilitation program, followed by a graduated throwing program. Here is a treatment algorithm proposed by Kadri et al ⁷ in 2019 that is intended to help with the clinical decision-making process.

Technique Description and Results

Once the patient is cleared for rehabilitation, the general principles are as follows: For the first 2 weeks, the goals are to build scapular, rotator cuff, and forearm strength while avoiding valgus stress and protecting healing tissue. For weeks 3 to 4, the goals are to progress pain-free through strength exercises and initiate controlled valgus stress with shoulder internal rotation exercises. For weeks 5 to 6, the primary goal is to increase the speed of movement in preparation for return to throwing. For week 7 and beyond, the athlete who remains pain-free can begin a progressive throwing program. It is always key in the rehabilitation process to remain pain-free. If at any stage during the process the athlete has pain with exercises, the trainer should regress or modify the exercise appropriately.

We will now introduce an example of a return to throwing program that follows these principles.

In weeks 1 to 2, we want to avoid valgus stress while strengthening the shoulder. Side-lying external rotations with a dumbbell works the posterior cuff. The key is to keep the elbow against the athlete’s side as he or she rotates the arm away from the body. Prone T’s will work the middle trapezius, rhomboids, and posterior deltoid. Ensure that the arm is straight and maintain a right angle between the body and the arm as the athlete raises outward.

Prone 90/90 external rotation strengthens the posterior cuff with the shoulder in a similar position of throwing. Ensure that the elbow does not drift forward or backward as the athlete performs this movement. This band series on the right involves 4 exercises intended to be performed with minimal rest in between. External rotation at neutral strengthens the posterior cuff. External rotation at 90/90 strengthens the posterior cuff in a position of throwing. T’s will strengthen middle trapezius, rhomboids, and posterior deltoid. Serratus press is intended to strengthen serratus anterior as the athlete shrugs the shoulders forward, similar to a bear hug exercise.

This slide demonstrates several forearm-strengthening exercises. On the left, the athlete is performing radial and ulnar deviation with a weighted hammer device. The video on the right demonstrates eccentric supination and pronation. The emphasis is on the eccentric portion of this movement only. The nonworking hand is used to help raise the weight back to the starting position and then the athlete slowly controls the weight down into supination or pronation.

Mobility of the forearm flexors is also a focus of the early rehabilitation process. Here athletes place a hard ball on the flexor-pronator muscle group and apply downward pressure with the opposite hand. They then extend the wrist and the fingers as they roll the ball proximally. This will help restore mobility in the flexor-pronator muscle group.

Kettlebell carries help strengthen the core and, depending on the specific type of carry, shoulder, forearm, and elbow strength can be incorporated as well. A bottoms-up carry emphasizes shoulder and wrist stability as the athlete has to balance the kettlebell in the upside-down position. The elbow should remain bent at 90° and the wrist maintained at neutral. Two-finger kettlebell carries emphasize finger and grip strength. Athletes are instructed to hold the kettlebell with only the index and middle finger as they walk with weight at their side.

As the athlete enters weeks 3 to 4, we begin to incorporate shoulder internal rotation strengthening. This movement was avoided in the first 2 weeks, as it places some valgus stress on the elbow. Internal rotation at the side is best done with a towel roll or a pad held between the arm and the rib cage to ensure the elbow does not drift laterally. Internal rotation in the 90/90 position will work the subscapularis in a position of throwing. The athlete should be closely monitored for recurrence of elbow pain when these exercises are initiated.

At this time, it is also recommended to start compound multijoint strengthening exercises. Push-up to downward dog is a push-up variation that emphasizes scapular strength and mobility. After athletes push up into the top position, they shrug their shoulders forward and then push their hips upward while pulling their head between their arms. The video on the right demonstrates 2 examples of compound movements for the upper back. In the TRX W to eccentric Y, athletes raise themselves up into the W position, extend their hands overhead into a Y position, and then slowly control their descent from the Y position. This helps strengthen the rhomboids, middle trapezius, and lower trapezius. Next, the dumbbell bent-over row strengthens the latissimus dorsi, rhomboids, and middle trapezius. Heavier loads are generally well tolerated for athletes in this movement. This provides an excellent opportunity for progressive overload, a central tenant of any strength and conditioning program.

In weeks 5 to 6, the goal is to increase the speed of movement in preparation for throwing. Quadruped ball drops in the 90/90 and Y position are a great exercise to start working on this. It is important that athletes keep their core engaged and do not allow their arm to drift from the 90/90 or Y position as they perform this exercise. This exercise can be done with a lightly weighted ball. The video on the right demonstrates a ball dribble against the wall in the 90/90 position. Again, this increases the speed of contraction of the rotator cuff muscles.

Upper body plyometrics should be incorporated to the program at this time as well. This medicine ball series demonstrates a chest pass and a scoop toss. In the chest pass, the athlete should assume an athletic position with hips and knees slightly bent. Instruct the athlete to chest pass the ball into the wall as hard as possible. The scoop toss works on increasing rotational power as athletes rotate the trunk as they pass the ball laterally into the wall as hard as they can. It is important to remind athletes that these are intended to be performed with maximal effort and speed. On the right, the athlete is performing a reverse throw with a lightly weighted ball. This works the throwing deceleration muscles in an explosive concentric manner in preparation for throwing. In throwing, these muscles will act eccentrically to decelerate the arm after release.

After 6 weeks, a throwing program can be considered if the athlete is pain-free. However, it is important to test the integrity of the UCL clinically before moving on to throwing. To do this, a moving valgus stress test can be performed. Since throwing a ball overhead places valgus stress on the elbow in flexion, the moving valgus stress test is preferred to the standard static valgus stress test, which is typically performed in only 1 position. In this test, the clinician applies a valgus force to the elbow in various degrees of flexion. If the patient has any pain during this test, he or she is not ready to start throwing.

Prior to any throwing session, it is extremely important that the athlete be warmed up properly. After a general full-body warm-up, we recommend a plyometric throwing warm-up. This series of 5 plyometric exercises is intended to prepare the entire body for throwing. The first exercise is 10 toes, which emphasizes trunk rotation. Athletes place their toes on an imaginary line, rotate the trunk back as far as they can, and then throw the ball. The next exercise is the figure-of-8, which is intended to establish a rhythm in the upper body as one goes through the motion of throwing. Athletes move their arm in a figure-of-8 motion prior to throwing. The next exercise, the lasso, similarly aims to establish upper body rhythm with a smaller lasso movement prior to throwing. The next rocker exercise begins to incorporate the lower body into the throwing motion. Athletes rock back onto their rear leg and then shift their weight forward as they throw. Next is the step-through exercise. In this exercise, athletes step behind the lead leg and then step forward with the lead leg as they throw.

Discussion/Conclusion

Return to throwing programs will differ for every athlete. We recommend using a velocity-based program rather than distance-based program, such as this one from Tread Athletics. With velocity-based programming, effort level is easier to monitor and progress.

However, if radar guns are not accessible to the athlete, here is an example of a distance-based return to throwing program, published by the University of Florida Sports Medicine Institute.

Here are our references.

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